Making Healthcare More Efficient: Going Big

Atul Gawande is one of the most interesting and perceptive observers of the healthcare scene. He is helped by being, as a surgeon, part of the scene, but in addition, he is an excellent writer. He strikes again with an article in The New Yorker: Big Med. He provides this lede: "Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?"

Gawande’s topic is efficiency in the delivery of healthcare. The means he uses to provide focus is a comparison of the way a large restaurant chain (Cheesecake Factory) provides services, and the way traditional physicians and hospitals provide services.
"Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key. It gives them buying power, lets them centralize common functions, and allows them to adopt and diffuse innovations faster than they could if they were a bunch of small, independent operations."

The traditional means of dispensing medical care might be considered the exact opposite model.
"Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital."

But the times are changing. The independent physician with his/her own office has been overcome by events. Whether or not one likes the details of the recent healthcare legislation, it has wrought dramatic changes in the healthcare system just by generating the universal conclusion that something must be done about runaway costs. Irreversible changes are occurring even before full-implementation of the law.
"Physicians were always predominantly self-employed, working alone or in small private-practice groups. American hospitals tended to be community-based. But that’s changing. Hospitals and clinics have been forming into large conglomerates. And physicians—facing escalating demands to lower costs, adopt expensive information technology, and account for performance—have been flocking to join them. According to the Bureau of Labor Statistics, only a quarter of doctors are self-employed—an extraordinary turnabout from a decade ago, when a majority were independent. They’ve decided to become employees, and health systems have become chains."

Gawande uses his mother’s need for knee replacement surgery to provide an example of how the old way of doing things compares with the developing "new’ way. The first task is to choose a hospital and then a surgeon to perform the operation.
"Boston has three hospitals in the top rank of orthopedic surgery. But even a doctor doesn’t have much to go on when it comes to making a choice. A place may have a great reputation, but it’s hard to know about actual quality of care. Unlike some countries, the United States doesn’t have a monitoring system that tracks joint-replacement statistics. Even within an institution, I found, surgeons take strikingly different approaches. They use different makes of artificial joints, different kinds of anesthesia, different regimens for post-surgical pain control and physical therapy."

Gawande choose his own hospital because it had a surgeon, John Wright, who believed that there was a knowable "right" way to do things. Gawande doesn’t use the term, but what he describes as the set of procedures Wright derived, could best be referred to as a protocol.
"’Customization should be five per cent, not ninety-five per cent, of what we do,’ he told me. A few years ago, he gathered a group of people from every specialty involved—surgery, anesthesia, nursing, physical therapy—to formulate a single default way of doing knee replacements. They examined every detail, arguing their way through their past experiences and whatever evidence they could find. Essentially, they did....the obvious thing to do: they studied what the best people were doing, figured out how to standardize it, and then tried to get everyone to follow suit."

This intent to focus on and use best practices produced an improvement in outcomes and in costs.
"The surgeons now use a single manufacturer for seventy-five per cent of their implants, giving the hospital bargaining power that has helped slash its knee-implant costs by half. And the start-to-finish standardization has led to vastly better outcomes. The distance patients can walk two days after surgery has increased from fifty-three to eighty-five feet. Nine out of ten could stand, walk, and climb at least a few stairs independently by the time of discharge. The amount of narcotic pain medications they required fell by a third. They could also leave the hospital nearly a full day earlier on average (which saved some two thousand dollars per patient)."

Gawande described a process that provided benefits in one hospital. The protocol arrived at was based on a limited set of data. A chain of hospitals can coordinate the accumulation of data and should be able to arrive at more precise recommendations by having better statistics. A government agency could collect nationwide data on symptoms, treatments, and outcomes and provide an even more powerful data base.

The description of how the restaurant chain introduces new meals might be compared to the introduction of a new medical procedure. A few experts work out the details of the most labor and cost effective way to arrive at a product with the desired quality. The rest is all in the training. Representatives of individual restaurants arrive and are given training in the selected procedures. They return to their restaurants and train the kitchen workers. The result is that each time one orders a specific dish one always gets the same dish, no matter what specific restaurant one might be in.

There is now no equivalent in healthcare. An individual physician will encounter thousands of situations. There is no way for an individual to know "best practice" based on their own experiences in more than a few instances. That is the function of scale and of the databases that come with it.

One of the issues raised by extending medical coverage to 30-40 million additional people is the rise in workload for an essentially constant number of doctors. This is usually considered in the context of the traditional physician model. How much more efficient would physicians be if they had a suite of protocols to assist them? A patient comes in with a set of symptoms. That set brings up a protocol that defines the likely causes of the problem and defines the most efficient way to sort through the possibilities and arrive at a diagnosis. The diagnosis will be accompanied by a recommended optimal course of treatment.

This sort of approach is not needed in all cases. Most things are easily recognized and treated. It is the complex cases that could indicate a serious threat to the patient’s health that require a more orderly approach. These are the situations where wasting time guessing at probable causes can be dangerous to the patient and expensive to the healthcare system.

If one believes that this approach is not needed, and that one is comfortable trusting in the competence of the individual physician, consider this comment from Gawande.
"In medicine, good ideas still take an appallingly long time to trickle down....One study examined how long it took several major discoveries, such as the finding that the use of beta-blockers after a heart attack improves survival, to reach even half of Americans. The answer was, on average, more than fifteen years."

One other aspect of scale that Gawande mentioned was quality control. Each restaurant has someone responsible for examining the meals pouring out of the kitchen and verifying that they have the desired characteristics. If a worker is not performing well he/she will learn about it and mend their ways. The trick will be to learn how to apply this principle to a herd of physicians.

Gawande describes one approach to quality control that is becoming common in hospitals: remote monitoring of intensive care units. A remote observer has several functions, including providing specialist advice. Some emergencies in the I.C.U. can draw attention from other patients that can be covered by the remote observers. Mistakes in treatment can also by recognized by having a backup observer.
"The concept of the remote I.C.U. started with an effort to let specialists in critical-care medicine, who are in short supply, cover not just one but several community hospitals. Two hundred and fifty hospitals from Alaska to Virginia have installed a version of the tele-I.C.U. It produced significant improvements in outcomes and costs—and, some discovered, a means of driving better practices even in hospitals that had specialists on hand."

This type of quality control requires scale to be efficient. It also requires physicians to leave behind their independent-operator model and recognize that they have become members of a team.