Tuesday, January 21, 2014

The Medical Perils of Error and Waste

"Variation equals opportunity" - words of Dr. Tom Lee, author of Eugene Braunwald and the Rise of Modern Medicine

He's got a point you know. We all have much thanks to give to variation - for if it weren't for variation, we as humans would undoubtedly not exist. Stealing a page from Darwin's On the Origin of Species, we see that evolution through natural selection depends and draws on this variation inherent to living things. The differences among individuals allow for competition, creating relative fitness; while within the individual, on a biochemical level, genes of sexually reproducing organisms are passed on to offspring, genomes are shuffled and variation is maintained within the population* (and this is important). For when, the circumstances change and the situation calls for a completely different set of traits for gaining a competitive advantage - dark features instead of light, speed as opposed to bulk - the "Greatest Show on Earth" takes center stage to showcase the utility of all of that wonderful variation - that that was on display and that that lay dormant - by mixing and matching until a more fit creature, possibly even species, emerges equipped for survival amid the new way of the land.

Of course, that's not the only possible end to this story. For the same reason that dinosaurs aren't walking alongside men today. Sometimes the genetic lottery comes out unfavorably and a species becomes extinct (and sometimes a giant asteroid collides with Earth).

Now think about this framework that I've laid out above, and instead of species let's think of health care systems. You may be privy to the tremendous amount of variation that exists in the United States' domestic system of health care today...We have patients who receive world class care and others who can't even access or afford care. We have primary care along with every kind of specialist and within each class we even have numerous different ways of practicing. We have a range of prices that we charge for essentially the same procedures. So a person going to hospital A might pay $4000 for X procedure, while a person who chooses to go to hospital B for X procedure pays only $3000...and I'm afraid that growing up dealing with its idiosyncrasies, we may have also grown deluded to believe that this is the way it has to be...

Luckily, we are beginning to see some ways out of this. First of all, with added transparency we can begin to map the variation that exists and persists in our health care system. Here, when I say we, I really mean Dr. John Wennberg and his colleagues at the Dartmouth Institute for Health Policy and Clinical Practice. For over two decades, the Dartmouth Institute has been collecting and analyzing stores of information on resource utilization via Medicare (our nation's single payer system), which insures America's 65-and-over population, and organizing their findings into freely available tools shared online at Dartmouth Atlas. Taking one quick look, it's not hard to see that things vary rather widely across the country, within regions and even within states and cities.

Mapping the variation in health care resource utilization across the fifty nifty United States. On their site you can zoom in and out to view different regions' variability on a range of topics in health care.

What this tells me, and Dr. Wennberg & Co. would agree, is that there is an incredible amount of waste in our health care system - waste defined as spending that doesn't result in better outcomes - by some measure almost 30% of all health care spending! Think about that. With health care spending running a total of $2.7 trillion a year, that means that over $800,000,000 is wasted per year! Think what we could do instead with all of that funding?? What a waste...

If that isn't enough, two weeks ago the Massachusetts Health Policy Commission released their Annual Cost Trends Report (full pdf), which showed that Massachusetts, the heralded gold standard of our domestic health care system, has exhibited 21-39% of spending as waste, measured at $14.7-26.9 billion in 2012. With much of our health care culture owing its roots to the values of the Hippocratic Oath, "first, do no harm", we're finding it harder to ignore the opposition to that rule apparent in these two distinct, but equally far reaching studies, and many else like them. In fact, it appears quite clearly, we do do harm, considerable harm at that (in the form of undertreatment, overtreatment and mistreatment or errors); to our patients and society at large.

Taking this all in stride, we're beginning to comprehend that, to some extent, we're all complicit.

But, there is hope. Going back to what I said earlier, in quoting Dr. Tom Lee, "variation equals opportunity"; we have our eureka moment. Our "Ah-ha I've got it!" If some are able to get by on less without adversely affecting health outcomes then how about we learn what enables them to do so and share best practices in order to bring all providers across our nation in line with a new standard of operation!? Some of you out there, with a few more years on me and your wits about you, may respond: "you mean what happened in the early 90's with HMO's (health management organizations)?" Expecting to get by on less, which equated to care rationing. For those unfamiliar to these times, care rationing is bad. And that's not what we hope to achieve with current and future reform efforts. No, instead we need to think bigger! We want to have our cake and eat it too!

I repeat. We can have high quality care and open access to it, covering everyone, improving the health of our population while cutting costs to increase affordability and reduce the financial burden of health care! Remember...Triple Aim'en! 

The question then is how do we get there?

Wednesday, January 1, 2014

Looking Ahead to 2014: The Dilemma of Transparency in Health Care

By now, I'd say it's fair to presume that the dust from last night's New Year's Eve bonanza has finally settled as many around the world gathered in city and town centers to celebrate the year that was while simultaneously turning over a new leaf, looking ahead to a new beginning in 2014. As the sun has set on Day 1 of the new year, marking the official start date of the Affordable Care Act (ACA), it's unlikely that anyone would be able to forecast with any certainty what we all have in store in the coming year. One thing I can state fairly is that the dust has far from settled in the individual health insurance marketplaces spread across the country - not even close in fact, as things have really just started to heat up! Over Christmas, the marketplaces played host to all sorts of activity as a few hundred thousand newly eligibles - those previously denied coverage due to pre-existing conditions in addition to those who previously held coverage now deemed insufficient - across the country were stirring (all through the house) to make their ways onto their respective insurance marketplaces to secure a health insurance plan for the new year (the best gift of all!).

The latest figures as of December 24th show nearly 2 million Americans having signed up for new coverage via the state and federally run health insurance marketplaces with the federal healthcare.gov website accounting for just over 1.1 million of that total - a drastic improvement from a few months back, but still a tad shy of the Health & Human Services' prediction of 3+ million by this date. Experiences in Massachusetts would suggest we have little to fret however, with still three months of open enrollment remaining (ending March 31, 2014).

This figure's title speaks for itself - health insurance enrollment data from Massachusetts, February - December 2007.

Despite these assurances, the media will most certainly be gearing up in all too characteristic fashion following the wake of yet another successful holiday season; with retail shops freshly picked clean, there will be only one logical story to turn our collective attention to - and that my friends is the tale of Obamacare, healthcare.gov and open enrollment. Over the coming month, fleets of straight shooting sensationalist reporters, who by definition never shy away from the heart of the issue, rather only becoming more bold as the issues become bigger, will inflict viewers with the usual onslaught of coverage on the new health care law, undoubtedly yielding stories of "promises" (broken, kept and empty), "trust", "accountability", "loved ones lost" and downright "fear" - a supreme repertoire fit for only the finest provocateur.

However, there is one word unmentioned thus far that may trump the lot when it comes to health care in 2014 and beyond. That is to speak of "transparency" in health care.

The word itself has shown increasing relevance in the legislation - jumping from being mentioned five times in Massachusetts' health care law of 2008 to a whopping twelve times in the corresponding legislation from this past year, just four years later. By no means a comparison of any statistical significance, it is however a hint, that we should take as signaling that maybe there's something to this word that the legislation has deemed worthy of repeatedly impressing upon, both in its legal and practical applications. Maybe it has something to do with the lack of transparency in health care to date??

For us to know exactly what the word entails for reform efforts, it's going to take a bit more than a simple show of hands from legislators. Rather, a more qualitative analysis must be employed - and for these purposes it will help if we remove our noses from the bully pulpit for a moment and take a step back to gain perspective on different ways that transparency could be applied in our ever increasing web of a health care system. For this exercise, it will be useful to recall the different players involved in our current state of health affairs; for a refresher, feel free to reference the list compiled in "Accountable for Change?".

As a means toward understanding what greater "transparency" may hold for different players in health care, we will be asking ourselves the following question:

What does transparency mean for _____________? Filling in the blank with one of the following:
"Patients", "Providers", "Payers", "Regulators", "Manufacturers", "Law", "Policymakers".