Healthcare Efficiency

“If you don’t know where you’re going, any direction will do.”  Most of the vocal forces in healthcare today seem headed in the direction of spending more money in the future.  Both Obama and Clinton advocate expanding health insurance to the currently uninsured, tho with slightly different approaches. 
The Commonwealth Fund recently published a proposal to expand Medicare and Medicaid to cover the uninsured.  In a fascinating slight of hand, they assert that the costs of their proposal would be partially offset by lower administrative costs.  Of course, they neglected to mention that the administrative costs for the uninsured are currently zero.  But this does resurrect the myth that the government can provide health insurance with a lower administrative cost than a private, for-profit insurance company.  While it’s true there are economies of scale (Medicare is huge), the government totally lacks the motivation to control costs.   Furthermore, Medicare has financial problems now, and it’s not likely they would welcome more obligations.

Nevertheless, it does seem likely that, come the revolution, we will see some proposal(s) to expand health insurance to the uninsured.  This will cost money--probably more than covering the currently insured, due partly to pent-up demand.  Any such plan will almost certainly include a mandate for everyone to play.  Can’t have the healthy invincibles opting out.  The California plan would have been an interesting model if the falling economy hadn’t sunk it prior to launch.  Everything costs money.

Speaking of which, the American public is focusing more on money these days than healthcare.  Problems paying for ______ (fill in the blank) top the list of concerns.  Not surprisingly, those with less income suffer the most.  Of those earning under $30 K per year, 63% had “serious problems paying for gas.”  Stay tuned, folks, it will get worse.  I don’t personally have that problem, but then I make more than $30 K, walk to work, don’t drive much, and my car gets 65+ miles per gallon. 

The Institute for Healthcare improvement has launched a new initiative, “Triple Aim” that includes:

• Improve the health of the population.  This is an important and welcome focus on public health.  Too many pundits point to statistics on longevity, infant mortality, etc. as an indictment of U.S. healthcare, whereas these are really public health issues.  Improving the health of the population will decrease the demand for healthcare.  Taking one more step back, improving air and water quality will improve the health of the population.  This seems axiomatic, but many fail to make the connection.  Try getting the EPA to admit that coal fired power plants will adversely affect polar bears.  Or conversely, that reducing emissions will improve the health of those living downwind. 

• Enhance the Healthcare Experience of Individuals.  Partly, this means improving customer service--common courtesy--by healthcare providers.  But partly other things, like efficiency of time, coordination of care, reducing errors, etc.  The interesting part is that almost all of this is free or actually pays a dividend.  You just have to want to do it.

• Reduce the per capita cost for the population.  At last (perhaps), someone is hinting at efficiency.  In most cases, they are talking only about reducing the amount of healthcare provided to the population.  Hopefully, IHI will also address the cost of individual healthcare services.  We referenced Porter and Teisberg’s book in the last post.  Effective competition would go a long way toward achieving these IHI goals, but it would require a major restructuring of our payment system.

Mirror, Mirror on the wall
What’s that in my crystal ball?
A fuzzy picture’s all I see
Of what the healthcare plan will be.

Posted by Dr. Robert Burney at 01:56 PM | Permalink | Comments (0)

No one goes to work intending to do a poor job.  With the possible exception of work slowdowns and similar temporary political strategies, no one tries to provide inferior goods or services.  But that is sometime the result.  Why?  
Last week, I read a book, Fatal Care, which is a compilation of events you don’t want to happen in your hospital.  Looking past the human drama, there are a few recurring themes that resonate with cases we have reviewed in my system.

Busy.  Not only that, but one consequence of being busy is that we skip steps that are designed to protect us from making errors that harm patients.  Routine checks that every nurse does before administering a medication--except when she’s busy.

Carelessness.  Picking up the closest syringe rather than the one intended for your patient--a syringe someone else had put down rather than dispose of properly across the room.

 
Procedures.  No one follows the rules, because there aren’t any.  The antithesis is rules that are so ancient and arcane that no one follows them anyway.

Protocols.  An ER doc once told me, “If you complain to me of the worst headache in your life, you get a CAT scan.  Period.”  That’s a protocol.  Then you follow the procedure for ordering the CAT scan.

 
Management.  Some smart person said, “The job of management is not to make people work but to make it possible for people to work.”  I came across a very old NEJM article yesterday that concluded that interns make fewer mistakes if they don’t work 24 hour shifts.  Well, gee whiz.  

History.  We must learn from the experiences of others.  The airline industry has certainly demonstrated the benefit of sharing our mistakes and near misses so that everyone doesn’t have to make every mistake.  Some preventive actions are mostly unnecessary but cheap insurance.  (The time out before surgery comes to mind.)

You can probably add to this list, from your experience, from the literature, from Root Cause Analysis of problems in your institution.  The point here is that there is a finite list, and we should have a strategy for each category.  Checklists help.  Pilots do this.  So do anesthesiologists.  The busier you are, the more necessary the checklist becomes.
Human beings make mistakes.  We all do.  We must design our systems to prevent the inevitable human errors from reaching the patient.  FMEA.  Another example of the migration of quality control principles from industry to healthcare.

But, does it pay?  There is some question about the financial return for quality initiatives.  The current Pay for Performance initiatives are not shining examples of the value of improvement.  They tend to pay for trivia that doesn’t improve anyone’s bottom line.  On the other hand, PRHI and others have demonstrated dramatic savings from preventing central line infections.  Doing it right does pay,  depending on the definition of “right.”  Compliance with someone else’s idea of what good healthcare should be may not add value.
I recall a Baldrige Award winner (manufacturing) showing a sign they used to have in their shop, “We make it nice, ‘cause we make it twice.”  Essentially everything they did came back for re-work.  Imagine thier bottom line when they finally got it right, and rework went from 100% to less than 1%.  We don't often get a chance to do it over in heatlhcare.

Elizabeth Teisberg is quoted as saying, “better health is less expensive than poor health.”  She is a strong advocate of competition in healthcare as a means to force improved value and lower cost.  Our present system does not provide meaningful competition, and this is one of the reasons costs keep escalating but care hasn’t noticeably improved.

Posted by Dr. Robert Burney at 11:44 AM | Permalink | Comments (0)