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?

I won't promise to have all the answers, nor do I think any one person does, but I can tell you what won't get us there - and that is depending on high technology solutions to human problems. We would be much better served if we divorce ourselves from the idea that we will find a cure to all of our ailments (like cancer), when at the end of the day, we still have to make human judgments when deciding a course of treatment - and have we gotten any better at that? Millions upon millions are invested into pharmaceutical and medical device innovation, but how much money do you think gets put towards finding more efficient ways to deliver care using the equipment and technology we already have? With all of our technological advances in the past fifty years, the U.S. still somehow finds itself with the world's 37th best health care system, just behind Costa Rica and just ahead of Slovenia.

Now, I would never choose to go back to facing widespread polio or having cardiovascular disease as a top killer - when a heart attack almost certainly meant a life was over - but I don't think all of today's ailments can be solved by power medicine alone. Like building up an army during peace time, we need to think about allocating some of our resources elsewhere.

My suggestions for where the bulk of our new found focus should go is to care coordination (care systems), alternative payment methodologies and public health, social services and other prevention efforts.

Our care could be better coordinated with the patient in mind. In fact, it's hard to think that our care could get any worse in terms of coordination. The old saying, "the left hand doesn't know what the right hand is doing", aptly describes much of what occurs behind closed doors in our health care system. The fact that there is no institutional memory in most places. That patient introductions and explanations have to be made again and again. To this end, it's no surprise that people get stressed out about their care. The dynamic of the patient-physician relationship for sure deserves our attention, but I also plead that we consider the physician-nurse relationship and the specialist-primary care relationship and all of the interconnections in our intricate system, including a greater integration of mental and behavioral health services. Our system right now is full of disparate dots. We need to connect the dots, and listen to the patient.

Another aspect of our present health care system, that I'm sure we're all too familiar with is the fee-for-service payment structure. In short, we pay more when more stuff is done. Meaning, that a physician makes her living by doing more. The more patients she sees, the more tests she orders, the more procedures she completes, the drugs she prescribes, the more that she's rewarded financially. The system pays by the service. So what do you we do? We serve.

Our leaders have begun to take a honest look at this incentive structure issue and have devised some different alternatives. Many of these solutions include some form of bundled/global payment and Accountable Care Organizations (ACOs). This approach, instead of paying for a service, supplies an annual budget to a hospital OR group of physicians OR group of hospitals and physicians, and tracks the groups spending against various health quality metrics for a select population. Once up and running, the group will be awarded and penalized for meeting or missing their quality goals. Therefore, the incentives should now align to encourage organizations to come up with creative, cost-saving, quality improving measures to meet the marks they've set - which spells all the better for patients!

Lastly, and arguably most importantly, we have public health, social services and prevention efforts. If we think back to the determinants of health diagram from "Accountable for Change", this covers everything aside from "health care" and "genetics" ("age", "sex" and "heredity"). Recent studies have shown that the U.S. fairs rather poorly compared to most developed nations in our investment in these types of interventions and services.

Above is a ranking of OECD countries by total spending on health and social service expenditures.  Posted by John McDonough of Harvard School of Public Health on his blog Health Stew, the graphic is originally derived from the book "The American Health Care Paradox" by Elizabeth Bradley & Lauren Taylor.

It comes as no surprise that the U.S. tops the list in terms of health expenditures, rationing about 16% of our GDP towards it (we already knew that we spend the most on our care). But, what might surprise you, is that the U.S. is nearly bottom of the list when it comes to spending on social services, and does indeed find the bottom when it comes to the ratio of health to social service spending. Is there something that the other countries know that we don't??

No. If only that were the case.

Here again though, it appears that things are beginning to turn around. Just a few weeks ago, a white paper was published by John Auerbach, Boston's former Public Health Commissioner, now with Northeastern's Institute on Urban Health Research, about Massachusett's Prevention and Wellness Trust Fund that was created through Chapter 224 of the Acts of 2012 to funnel $60 million over four years into public health initiatives across the state. This is a huge step forward in terms of reallocating our resources appropriately - to take some of that waste, i.e. money invested that yields no further improvements, and put it towards areas that have the potential to drastically affect population health. The discipline of public health sees prevention as its best weapon and upstream drivers of health as its bulls-eye. If you can stop something from happening altogether, by investing in measures that get at the root causes of major issues in health, then you will find yourself paying for less catastrophic repairs and in sum, less spending overall. Which is good, because maybe, just maybe, this $60 million, which mind you is less than 0.1% of Massachusetts' total health care spending, will help to make those future costs, first grow at slower and slower rates, and then maybe, just maybe...well, let's not get ahead of ourselves.

Either way, after all this change, we may find ourselves with a health care system almost unrecognizable from the one with which we began. Hopefully, for our sake it's evolved better fitness too.

Craving for more discussions about modern medicine, how we got to where we are and how we'll get to a healthier, more cost-effective future? Check out this recent podcast from WBUR's Open Source, where host Christopher Lydon welcomes Dr. Tom Lee and Dr. Donald Berwick to the show, and gets their takes on all of this health care madness of which I've only begun to scratch the surface above.

*In most cases anyway...Populations that have very little variation will tend to not become more varied. This is a problem in which we typically see an overabundance of recessive conditions (genes that require two of the same allele to be expressed), and less of a capacity for evolution. 

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