Source: US Census Bureau, WHO. Compiled by CNN.We know the commonly cited statistics: the United States of America spends more money on health care than any other country, yet the health outcomes of this expenditure are far from the best (between 20th and 50th, depending on the indicator). As future health care providers, it is incumbent upon us to address this discrepancy, since it leaves countless patients unnecessarily sick (and in financial debt). A brief glance at the current debate reveals a number of root causes as identified by a variety of groups: administrative overhead, malpractice insurance and defensive medicine, better (more costly) technology, more availability and promotion of prescription drugs, a growing population of elderly patients coupled with more intense end-of-life care...
“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.This is the hook to surgeon-writer Atul Gawande's recent article in The New Yorker about the causes of health care costs in the USA. For this article, he traveled to McAllen, Texas, whose expenditure on health care is second only to Miami. On the ground, he spoke with physicians, hospital administrators, local business persons, and working-class residents. His research and conversations indicate that the principle reason for increased health care expenditure is that physicians in McAllen are systematically overusing medicine.
Physicians as Gatekeepers
If we look at the distribution of health care expenditure (below), physicians control the majority of decisions about expenditures...and rightly so. After all, shouldn't trained healers be the ones working directly with patients to determine the appropriate services to provide?
U.S.A. National Health Care Expenditures, 2006
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group.
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group. Compiled by the Kaiser Family Foundation.
Despite this key role, however, gatekeeper physicians have received relatively little attention/scrutany until recently. Drug companies, insurers, hospitals, and medical device manufacturers traditionally dominate the national conversation. Gawande reminds us of the central role that physicians play in the health care system - for better or for worse.
Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do."Blind Spots": Personal Bias in Medicine- Atul Gawande, "The Cost Conundrum"
At the Second Annual (Student-run) Cultural Competence Workshop at BUSM, Prof. Linda Barnes spoke about cultural "blinds spots" that physicians may bring into the patient room. She mentioned biases with regard to cultures of race, class, gender, education, nationality, BMI, etc. But why does this matter? Most people would contend that very few physicians are outright "racist" or "sexist." The impact of subconscious "blind spots", however, is subtle and often occurs when medical decision-trees are less clearly defined. One example from Gawande's article describes a study done on physicians from high- and low-expenditure cities who were given sample patient cases with a ranging degree of established treatment protocols. They found that...
...in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.So what is it about place (high- or low-expenditure city) that is related to use of medical services? A comparison between McAllen and El Paso, Texas - a city with similar demographics and significantly lower health care expenditure - indicates that this difference is unrelated to physician training, patient needs, availability of technology, or physician incentive structures. So what is the X factor?- Atul Gawande, "The Cost Conundrum"
Economic Culture
About fifteen years ago, it seems, something began to change in McAllen. A few leaders of local institutions took profit growth to be a legitimate ethic in the practice of medicine. Not all the doctors accepted this. But they failed to discourage those who did. So here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.Rather than a culture of race or gender influencing medical decision-making, Gawande posits that a culture of profiteering took hold in McAllen and, furthermore, threatens to dominate the national health care scene. The reason that this culture permeated McAllen is a combination of individual actions and systemic context. In a health care system that compensates quantity over quality and that promotes individualism/fragmentation over teamwork, individual revenue-leaning physicians were easily able to shift their behavior from using only necessary labs & procedures to using the maximum possible.- Atul Gawande, "The Cost Conundrum"
How to Transform a Revenue-focused Culture to a Healing-focused Culture
While McAllen may be an outlier, it represents an extreme that has the potential to spread throughout the current health care system, further-sending health care expenditures through the roof. Fortunately, in better defining the nature of the issue in terms of medical culture, Gawande implicitly points us in the direction of a solution: cultural re-shifting towards collaborative, quality-driven medical care. In designing a cultural shift, one must do at least three things:
- Establish principles of the "new" culture
- Create mechanisms for turning these principles into action
- Disseminate the principles and mechanisms to the target market (ex. physicians)
1. Establish principles of collaboration, quality-focused and patient-centered health care.
It seems that in our current state of high-cost, low-quality health care, we have spend much of our energy on cost-containment - this being the mantra of current health reform efforts. This seems consistent with the philosophy of W. Edwards Deming, a management consultant who "made a significant contribution to Japan's later reputation for innovative high-quality products and its economic power" (Wikipedia), who noted that when organizations focus on cost, then over time costs rise and quality falls. On the flip-side, however, when organizations focus on quality, then quality improves and costs fall. Although simplistic, this philosophy is echoed by Prof. Michael Porter, an expert on competitive strategy who recently focused his attention on competitive environments in health care. Porter (2008) states that in order to be successful, health reform must be guided by three principles:
- A common goal of value for patients (i.e. patient-centered)
- Medical practices organized around conditions and care cycles (i.e. collaborative)
- Measurement of results (i.e. quality-focused)
2. Develop mechanisms for implementing the principles of good care.
Delivering health care based upon the principles of collaboration, a focus on quality, and patient-centered care is a challenge given the fragmentation and quantity-focus of current policies. The PCMH is an attempt to implement the guiding principles within the current system. This following video from the AAFP describes how, by combining traditional primary care and family medicine with modern technology, the PCMH has already been integrated into existing clinics and has produced better health outcomes, improved physician job satisfaction, and reduced costs. Satisfied early-adopters include IBM, which had the following endorsement: "IBM believes that the Patient-Centered Medical Home addresses the core issues of what's lacking in health care."
The Patient-Centered Medical HomeThe value of the patient-centered medical home in the words of patients, physicians, employers and policy leaders. From the AAFP.
3. Actively promote adoption of principles and mechanisms
How does one engineer a culture shift? One answer lies with the experts of massive behavior influence: Coca-Cola, Philip-Morris, Nike, etc. In promoting a culture shift, these organizations use active approaches at multiple levels to meet their goals of maximizing revenue: lobbying for public policies, focused marketing campaigns, word-of-mouth, and more. In the realm of public policy-making, however, these ideas have lagged far behind the private sector. Only in 2008 was the term "culture change" with regard to public policy coined by Knopf et al. in their paper, "Achieving Culture Change: a policy framework." Knopf et al. integrate ideas from behavioral economics - a field that combines human and social sciences (esp. with decision-making theory) with economic models - with traditional policy-making theory (ex. incentives, regulations and legislation) to describe multi-level approaches to enacting more effective public policy. In effect, they are adopting the strategies of the private sector.
However, while Knopf et al. describe both society-wide (ex. economics, media, & law) and individual (ex. peers, family, community & workplace) influences on culture change, Gawande seems to point out that in our current discussion of health care reform, individual-level influences (i.e. "anchor-tenants") are being left out. In his popular book, "The Tipping Point: How Little Things Can Make A Big Difference," Malcolm Gladwell explores the nature of how individual-level actors can create epidemics of products, ideas and behaviors (ex. AYBABTU). In relation to the innovation diffusion curve (below), Gladwell describes three major agents that can drive an epidemic:
- The Maven - collectors of knowledge. They are the "early adopters" in the Innovation Diffusion Curve below and constantly have their ears on the ground.
- The Connector - knows a lot of people. They take innovations and disseminate them to the right people.
- The Salesman - powerful persuaders. They help bring an innovation from early adoption to larger diffusion.
Innovation Diffusion Curve
How can one reach the Mavens, Connectors and Salesmen of the proposed epidemic of quality-driven medical care? Much like pharmaceuticals target key enzymes (i.e. "hubs," the Kevin Bacon's of the cellular world), the promoters of the culture shift must specifically target Gladwell's agents of change. The well-organized and broadly-based medical societies (ex. AAFP, AMA, APS, etc.) offer one potential route for specific targeting. They have identified leadership and local chapters that can quickly disseminate and gather information. These chapters have the ability to administer brief surveys to their members that could identify the potential change agents in their community of physicians (ex "How many physicians do you have weak ties with in your community?", "How many medical journals do you keep updated on?", etc.). Once these individuals are identified, local or regional chapters can host workshops designed to empower these agents of change to develop an intentional culture of collaborative, quality-focused and patient centered medical care. This is the most effective way of using few resources to have the greatest impact on individual level elements of culture. The time for health reform is now, and, as Gawande warns, even if we improve finance structures, if we don't address physician culture, we could still see trends of higher expenditure and lower quality.
The decision is whether we are going to reward the leaders who are trying to build a new generation of [collaborative and quality-focused solutions]. If we don’t, McAllen won’t be an outlier. It will be our future.What do you think?
-Atul Gawande, "The Cost Conundrum"
- Are physicians really responsible for high-expenditure in health care?
- Can the PCMH address issues of quality-improvement and cost-reduction?
- If so, is a cultural change possible?
- Do we have a right to "engineer" culture change at an individual-level or is it up to traditional policy?
- Do physicians (as a social group) have a responsibility to improving society-wide health?
References
- Bein B. "PCMH Gets Off to Slow Start in Nation's Medical Schools." AAFP News Now. 2009.
- Gawande A. "The Cost Conundrum." The New Yorker. http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
- Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference. Little Brown. 2000.
- Knott D, Muers S, Aldridge. Achieving Culture Change: a policy framework. 2008.
- Landau E. "Life expectancy could be topic in health care debate." CNN. http://www.cnn.com/2009/HEALTH/06/11/life.expectancy.health.care/index.html#cnnSTCText
- Porter M, Teisberg EO. "How Physicians Can Change the Future of Health Care." JAMA. March 14, 2007.
- Stange KC. The Problem of Fragmentation and the Need for Integrative Solutions. The Annals of Family Medicine (2009) vol. 7 (2) pp. 100-103
- Wikipedia contributors. W. Edwards Deming. Wikipedia, The Free Encyclopedia. June 18, 2009, 01:36 UTC. Available at: http://en.wikipedia.org/w/index.php?title=W._Edwards_Deming&oldid=297073705. Accessed June 18, 2009.
