Healthcare Efficiency

Sara Collins, writing for the Commonwealth Fund, argues against HSAs (a.k.a MSA plus High Deductible Health Insurance).    Let’s look at her main points: “Higher patient cost-sharing is the wrong prescription.”  True, we do already pay more than most other countries, but not enough yet to make us price conscious.  She then says, this would “lead patients to decide against getting healthcare they need.”  Wow!  What a patronizing remark!  Who decides “need?”  Later, she answers this by stating that governments, accrediting organizations, and professional societies “are much better positioned to insist on high performance.”  Or, “Trust me.  I know what’s best for you.”   Somehow, I don’t think the American public is into letting the government make decisions for them.  If people skip or delay healthcare that Dr. Collins thinks they should have, I think  that’s OK.  It’s their decision.  She is correct that patients today are in a poor position to make decisions--they don’t have information and they really don’t have the power to make choices.  But that doesn’t mean we shouldn’t try.  Many of her remaining arguments focus on the fact that HSAs wouldn’t help the uninsured (true) and the tax savings would be of greater benefit to higher paid workers.  (Also true).  So what!  This is not a social program.  It’s a step in the direction of making patients more cost-conscious, which will eventually drive down costs for everyone.  One of her solutions is to legislate the cost of health insurance premiums.   Sure!  She does have a few good ideas:  networks of high performing providers (if only Medicare had the guts to limit choices to those), disease management, and improved access to primary care.  True, if you get sick, your out-of-pocket costs will be higher with an HSA than with and indemnity plan.  But most illness today is related to patient choices.  (smoking, obesity, inactivity, etc.)  Want to reduce your costs?  Take care of yourself.   [Off to the ASQ Healthcare Quality meeting in Houston]

Posted by Dr. Robert Burney at 09:17 PM | Permalink | Comments (0)

HSAs, MSAs, HDHI, Flex Spending, etc. are all designed to make paying for healthcare easier for consumers, AND make consumers more conscious of costs.  These are coupled with efforts to provide information to consumers on the “quality” of providers and thus facilitate decisions.  Problem is, the ivory tower concepts of “quality” (conformance to standards) isn’t quite in line with consumer concepts.  For most consumers, technical quality is assumed.  (That may not be justified, but I think it is true.)  They depend on accrediting organizations, government oversight, and hospital boards to assure satisfactory technical  performance.  They want to compare costs and service quality.  As John points out, “costs” means out of pocket costs.  Service includes things like wait time, information sharing, free parking, friendly staff, clean facility, etc.  You can’t find this sort of thing except by asking friends and neighbors.  That’s one reason patients don’t use the sites available to compare “conformance to standards.”  One argument against publishing prices and fostering cost competition is that it would diminish hospitals’ ability to cost shift--overcharging in one area to compensate for losses in another.  But this is one of the main reasons healthcare costs so much--it is expensive.  In other words, institutions are allowed to charge too much, because there is no price pressure.  Which brings us back to efficiency.  If you are a provider of an expensive service, and a competitor offers it for 30% less, what do you do?  If you want to maintain your margin and your profit, you have to become more efficient or be priced out of the market.  It works in business, it can work in the business of healthcare, but we need to become a lot more transparent to make this work.  Consumers need more information on prices and they need the power to make purchase decisions.  Then costs will decrease.

Posted by Dr. Robert Burney at 07:43 PM | Permalink | Comments (0)

The most common complaint about healthcare from non-medical acquaintances is the cost.  Among those who have experienced healthcare recently, cost is replaced by poor service as the prime concern.  However, no one is looking at the cost of individual healthcare.  There is no competition for healthcare on the basis of cost of service.  AHRQ has forbidden any discussion or research on this subject.  Imagine if we transferred this rhetoric to automobiles:  You would not know the price of a car until you bought it.  No one would compete for your business on price or quality.  The entrenched bureaucracy would wring it’s hands over the number of people driving and the poor who couldn’t afford cars.  And since the government paid over 50% of the cost of your car, and your insurance paid most of the rest, you wouldn’t really care what it cost.  Of course, it wouldn’t work well, because you don’t make the purchase decision, so manufacturers wouldn’t care what you thought.  That’s US healthcare today.  Flexible Spending Accounts ( I have one) reduce some personal cost by allowing payment from pre-tax income.  Medical Savings Accounts must be coupled with High Deductible Health Insurance (what’s that?) but offer other advantages.  For definitions & details, see the US Dept of Labor.  Neither has gained much traction in part because the hand-wringers fret that neither solves the problems of the unemployed and the uninsured.  Well, duh!  They weren’t intended to be social programs.  The familiar argument is trotted out that these would siphon off healthier, employed individuals, leaving sicker patients for traditional plans and thus increasing premiums.  And the alternative is . . . ?  That’s right.  Do nothing.  A pluralistic health system (ours) could use a pluralistic payment system--especially one that increases consumer interest in unit healthcare costs.

Posted by Dr. Robert Burney at 08:34 PM | Permalink | Comments (1)

Here’s one from today’s email:
“Dr. B, The NP you just hired has applied for access to our electronic medical records.  Please fill out the attached form so I can give her a password.  M.”
“M:  This is non value-added bureaucracy!  Her position as an NP with us conveys access to medical records.  The password should come without asking.  Dr. B”
“Dr. B:  No.  This form has been required for the past five years.  We have always done this.  M.”
A small waste of time.  A minor inefficiency.  The real problem is the failure to recognize it as such.  Where is the compulsion to improve!  To make processes faster, better, cheaper!  How do you inspire employees to think critically about what they do.  
In another life, I told an anesthesiologist the tests she had ordered were without value to the patient.  “Oh no!” She replied.  “They must be valuable.  We do them every day.”
It’s the same thing.  Thoughtless plodding in familiar tracks.  “If you always do what you’ve always done . . .etc.”  Some of this is a resistance to change, but mostly it’s just  a failure to see the waste around us.  A lack of desire to improve.  A failure to think critically about what we do.   This, I think is a leadership issue--to inspire a culture of quality.  AHRQ has developed a survey to assess the culture of safety in institutions.  Perhaps we need a survey tool to assess the culture for improvement.   Most improvement isn’t expensive:  A form deleted, a test not ordered.   All it takes is the culture to inspire it.

Posted by Dr. Robert Burney at 09:41 PM | Permalink | Comments (0)

Does the title apply to your healthcare organization?  Maybe it should.  Check out the current issue of Quality Progress for “Make Healthcare Lean” by A.Manos, M.Sattler, and G.Alukal.  Another application of techniques from industry.  Good ideas under “Tools and Techniques.”  Many obvious, but we still don’t use them: Organize the workplace, so you can find tools and supplies.  (Without looking, where is a pencil on your desk?)   Standardize work.  Do the same thing every day, and learn to do it well.  Quick changeover.  This speaks to me!  The OR doesn’t make money while it’s empty.   We used to schedule all the left eye cataracts in the AM, right eyes in the PM to minimize time in moving the microscope.  Same for knee arthroscopy.  Interesting quote from Henry Ford: “The longer an article is in the process of manufacture and the more it is moved about, the greater its ultimate cost.”   We calculated the $ cost per minute a patient was in our facility.  The trick was to move them out without their feeling rushed.  Nausea was not allowed, and good pain control was mandatory.  All of this is possible, but it doesn’t happen by accident.  Discussion of causes of waste in healthcare:  Overproduction.  (e.g. paperwork).  Our patient chart was six pages.  Total.  Everything.  We counted (and minimized) penstrokes.  Inventory.   Next time you do an inventory, put a $ value on each cubby hole.  Take all the cupboards out of the ORs.  Bring in only what you need and return the extra to inventory when you’re through.  How about the anesthesia cart!  Finally, waiting.  “In any form, waiting is a waste.”  Is there ever a time when the patient is on the OR table, but nothing’s happening?  My ORs used to cost $20 per minute.  Do the arithmetic.

Posted by Dr. Robert Burney at 08:35 PM | Permalink | Comments (6)

The 2004 meeting of the ASQ in Canada coincided with the publication (CMAJ 170:1678-1686,2004) of a study of adverse events in Canadian hospitals.  They reviewed 3,745 charts in hospitals in 5 provinces for adverse events (AE).  The incidence of AE overall was 7.5 per 100 admissions and 36.9% of those were judged to be preventable, and 20.8% resulted in death.  AEs led to 1,521 additional hospital days.  Since the government owns all the hospitals, the data are probably reliable.  The remarkable thing is the similarity with the numbers reported in the 1999 IOM study from the US.  We are, thus not really different from the healthcare systems in other developed countries.  Certainly no worse.  In spite of beating ourselves up over quality of US healthcare, we are probably the best in the world.  Now, there’s a depressing statement!  The actual truth, as the IOM said, is that we have the capacity for doing well but we don't do so consistently.  There are, indeed, pockets of excellence in our system, but that’s not good enough.  Roger Resar, writing for the IHI, talks about “reliability”, aka consistency.  The importance of doing the right thing every time.  Good healthcare should not be an accident, and when we achieve that goal, bad healthcare will not be an accident either.  In other words, when you do it right every time, there is no room for mistakes.  Fran Griffin, also at IHI, talks about standardization, “because that’s what promotes reliability.”  Protocols.  Practice guidelines.  Do it the same way every time.  Of course this patient will have pre-op antibiotics.  Every patient gets antibiotics before surgery.  This approach is antithetical to our culture but it is critical  for improvement.

Posted by Dr. Robert Burney at 11:21 AM | Permalink | Comments (0)