Chasing the Rabbit: Official Blog by Author Steven Spear

Dear Friend and Colleagues,

Congress and the opinionators are plowing ahead on health care reform that is the wrong cure for the wrong problem.  Committed to competition among insurers (with a public option to add competition), they entirely miss the key point: Too many resources are wasted and too much pain is caused by the presence of inept organizations who provide crummy, expensive care because they aren’t filtered from the system.

Why aren’t they? When you decide where to get care, you lack information sufficient to pick the most effective and most efficient, so you trust your wealth and well being to a blind draw.  This drives business to those who don’t deserve it and away from those who do.

The solution? Transparency about provider performance to allow informed choice by payers and patients.

Below, I’ve attached a letter I sent to the NY Times expanding on these points.

When you’ve read it, please comment and let me know what you think.

Ideally, I would like to get sufficient feedback that we can send an op ed to major papers, letters to Congress, and the like saying what _we_ want in a reform package—we being real patients, real providers, those in the thick of trying to reform the delivery of health care at the bedside and in the exam room, not just the know nothing talking heads.

Here are some ideas. Let me  know what you think we should add, modify, or delete.

1. Visibility about information.  Without it, we’re picking providers by shooting in the dark.  Let providers compete for patients who are making informed choices.
2. Bona fide competition among insurers, so we get the best _portable_ plans at the best price.
3. A social safety net for the underprivileged who cannot provide for themselves.

I’m sorely convinced that if we don’t act, what comes out of Washington may actually be worse than what we have.  Certainly, it will be much worse than it can be or should be.

Steve

Dear Sir or Madam:

According to the NY Times opinion pages (”A Public Health Plan,” editorial NYTimes, June 20, 2009; “Health Care Showdown,” Paul Krugman, NYTimes, June 22, 2009), the primary problem with US health care is the lack of competition among insurers.  Certainly, local monopolists will inflate fees and deflate service, and one would expect that genuine competition among several providers is better than none.

However, even where there is competition among insurers, quality is poor and costs are high.  Why?  There is insufficient competition among providers, and this lack of competition matters a lot.

Currently, there are extraordinary differences in performance, with some providing great care–consistently good outcomes, few if any complications, minimal waits and available access, all at reasonable costs, while others provide terrible care–inconsistent outcomes, many complications, and high costs.

Given those painful discrepancies, patients and payers should swarm to the good and spurn the bad.  But they don’t.

Why?  Because we don’t have sufficient information to know better, and, without informed choice, far too much traffic goes to those who burn a lot of resources while providing too little, and too little traffic goes to those who are most effective and most efficient.  (Imagine such blindness going into a purchase by considering buying a car, and not knowing in advance whether you will get a Lexus or a Yugo for your hard earned money, or buying a plane ticket not knowing to which airport you will arrive.)

Because those who receive care and pay for care cannot determine well where to get care, the overall level of care is tragically lower than it need be and its costs are astronomically too high.

Here is a starting point to solving that problem.  There are certain events that just should never happen (just like the wheels of your car or the wings of your plane should never fall off).  Patients on ventilators shouldn’t get pneumonia, patients with catheters shouldn’t get urinary tract or blood stream infections, patients shouldn’t suffer surgical site infections, patients should not fall and injure themselves, and patients should never get the wrong medication, in the wrong dose.

When these things do happen, it is not because “health care is complicated” or because “every patient is different.”  It is because there was a breakdown in the delivery of care.  The management of care was broken.

Therefore, let us know how often it gets broken.  Require all organizations to post how well they are doing against a standard of ‘zero’ on these never events.  Next, build out other measures of efficacy and efficiency across the span from preventative and primary care to chronic, acute, intensive, and extended care.  Then, people can make informed choices as to whom to trust with their wealth and well being and whom to fear.

Without doubt, a caring society will ensure that the least fortunate receive health care just as we try now to make sure no one goes hungry or homeless. And yes, it is undoubtedly important that there be competition among insurance providers.  No one wants to get fleeced.

However, if we want bona fide reform that successfully increases quality and affordability (and hence access), we have to start rewarding great providers at the expense of the laggards so the money we put into the system gets well spent, not squandered.

Only then can we get health care for all in a way that isn’t bankrupting.

Yours,
Steve Spear

Senior Lecturer: MIT-Engineering Systems Division
Senior Fellow: Institute for Healthcare Improvement

When asked by Pimm Fox on Bloomberg Radio what I thought of health care reform proposals, I answered that they all miss the larger point: We spend too much and get too little because patients and payers cannot distinguish good providers from bad.  This drives down quality and drives up cost–financial and human suffering (Please read the rest of this post to see why transparency is so critical.) Read the rest of this entry »

Does it make sense to travel overseas for surgical and other medical procedures in pursuit of lower cost care?  In the view of writers Arnold Milstein, Mark Smith, and Jerome Kassirer, we don’t rightly know (”Overseas, Under the Knife,” NY Times, June 10, 2009).

Why? “The only way to know is to find out how foreign hospitals and surgeons compare with their American counterparts.”

The problem? “We can’t know until we can directly compare the outcomes with those of American surgery.”

The solution? “To begin, we must adopt a uniform way for American hospitals and surgeons to report on the frequency of short-term surgical complications.”
“Patients and their surgeons also need comparable measurements of long-term success.”

The current state? “So far, however, only a small minority of surgeons participate in this or any other valid national system of reporting surgical outcomes.”
…even though…”The system used for many years by Veterans Affairs hospitals to reduce surgical complications is the best option for this [tracking short term complications], since it is available to all American doctors through the American College of Surgeons.”

The NY Times perpetuates a counterproductive falsehood, that better care for more people will be more costly (”Paying for Universal Health Coverage,” NY Times, June 6, 2009).  This isn’t true but claiming so only confuses the policy choices we have to make.  The assertion of more care for more cost is based on the often repeated by disproven assumption that resources are spent with optimal efficiency and effectiveness.  They are not.  Everyday there are trivial and catastrophic costs–human and financial–from the haphazardness by which care is delivered–each speciality operating as if in isolation–coming together by chance or by the diligent but often inadequate efforts of patients and families.

This need not be.  Pioneering providers have shown that well coordinated care is not only safer, not causing harm, it is less costly.

The Times would do itself, its readers, and society a great service by changing its advocacy from more care at greater cost to more care at less cost and by insisting that reform reward those who combine great care, for many patients, at lower cost and punish those who drive up costs and drive down quality.

Would  you buy a General Motors or Chrysler car?  That was the question put to me by Pimm Fox during a Bloomberg Radio interview on Thursday, June 4th.  My answer?  Only if they combine quality, functionality, and cost that beats their competitors.

His next question, What’s the chance that they will?  That depends on the company.  The chatter on Chrysler is that their owners took a fairly cynical approach–managing the company for sale or merger, not for self sufficiency.  So, the brand-name and sales channels were left intact, but new product development was reportedly gutted.  From what I’ve heard, there is no product in the pipeline, so if you buy a Chrysler, you’ll be getting technology one, two, or more years out of date.

General Motors is a different story, a bloated but nevertheless self-reliant organization (functionally, if no financially).  The big problem is there is tempo.  A management system built for simple markets, products, and processes sixty years ago isn’t agile enough for today’s complex and dynamic situation.

The solution? Everyone at General Motors–Fritz Henderson on down–starting the day with the question: The work I do, why can’t I do it in half the time? and ending the day with some understanding of how to extract more time while creating more value.  Faster to identify market need, faster to design market delighting products and services, and faster in their delivery.  That is how ‘high velocity organizations’ get ahead and stay ahead of their rivals.