It seems that Obamacare has people talking in the mainstream media
about healthcare innovation--this is GOOD. Discussions about funding
and about service delivery can be found in the daily news. The
question of “if healthcare delivery will change” is no longer
seriously on the table.
Payors and providers are already doing
business differently. This post will look at healthcare reform and
the objections to the Affordable Care Act through the lens of Dr Atul
Gawande and The Cheesecake Factory. His article,
BigMed, was published in the New Yorker.
People do not seem to be talking as much about medical education,
managing change for providers, or about the effects of
accountability.
In the current fee-for-service model the goal is to deliver as
many billable services as possible. In the emerging
per-member/per-month (pmpm) model the goal is to use less money than
is available. PMPM shifts the risk of over-spending from the payor to
the provider. The initial goal is to deliver as many low-cost
services as possible; the old model focuses on the delivery of
expensive services to promote increased billing. The new model
encourages outreach, screening, prevention, and care coordination for
the most complex cases.
One of the new realities of healthcare finance is that profits
will come from savings in service delivery. Not from delivering more
services. A floor is established for patient care through the use of
outcomes. Meet the outcomes under budget and pocket the difference.
Steve Denning, author of RADICAL MANAGEMENT: Rethinking leadership
and innovation, wrote a
rebuttal
in How Not To Fix US Health Care: Copy The Cheesecake Factory.
Denning opposes a view of healthcare as routine and reducible to
discrete functions; many of us would agree. However, reality is that
most care is routine and can be flow-charted.
This rebuttal is built on the assumption that competition will
enforce efficiency. While this may be true in larger markets, it is
less true in smaller markets where there is much less competition,
and even functional monopoly. It also supposes that there is current
accurate information about the competition available to inform
consumers of their choices.
Denning gives us the following model to organize the healthcare
umbrella:
"As Clayton Christensen and Jason Hwang pointed out
in their book, The Innovator’s Prescription (2009), the first step
in making some sense of the US health care system is to get clear on
“what is the job to be done?” They distinguish three very
different “jobs to be done” in health care organizations:
Solution shops, which are organizations structured to
diagnose and solve unstructured problems. These require skilled
experts who deploy expertise, intuition and analysis to diagnose and
find solutions to complex problems. An example would be Gawande’s
elderly woman who fainted and fell: the first task is to figure out
what is her problem.
Value-adding processes: organizations which take things
that are broken and turn them into higher value things. Both the
problem and the solution are largely known. The challenge is to
deliver the solution efficiently and effectively. Knee-replacement
surgery would be an example where a value-adding process is
appropriate: the problem and the solution are largely known.
Facilitated networks are arrangements in which people
exchange things with each other. Chronic care of diseases like
diabetes are best handled through community-based networks. It is
known what needs to be done: it’s mainly about getting patients to
do it."
One place where the factory model is
being used in healthcare is in the use of hospitalists. “Back in
the day...” primary care doctors admitted patients to the hospital
and then managed care for their own patients; this on top of their
outpatient duties. In order for physicians to have more control over
their work schedules the position of hospitalist was created.
Hospitalists admit patients for inpatient care and manage routine
care, coordinating with specialists as necessary. Inpatient care is
an example of Christensen and Hwang's value-added process.
This new system offers benefits for
physicians. Greater flexibility in scheduling for all physicians in a
community becomes possible when inpatient care is carved out. A
career ladder is built as new physicians work off loans, gain
experience, and consider where they want to practice.
While there are benefits for
physicians, patients may have different experiences. Hospitalists are
often early career professionals with little experience independently
managing patient care. This can lead to uneven care, and mistakes do
happen. Continuity between hospitalists may also suffer as each
doctor continues to think of themselves as an independent
practitioner, rather than part of a team. Adding a supervisor and a
coordinator—a team leader—to the mix could add quality control
and reduce patient dissatisfaction (I have a couple horror stories
that would illustrate a lack of quality).
Dr Gawande introduces a career ladder.
Everyone he talks with has worked themselves up the responsibility
food chain, with presumably greater rewards of autonomy and pay. Too
often new employees expect to start at the top. But even experienced
workers entering new work sites or new careers start at the bottom.
Even professionals, like physicians and mental health providers, land
in this trap.
To support a career ladder mentoring and supervision are required.
This equates to the quality control function of team leaders as
described by Dr. Gawande.
Popular perception of professional education is out of step, often
setting up unrealistic expectations by students and early career
professionals. Graduate and professional schools might consider
increasing transparency in how career progressions happen.
It seems to me that folks are dug-in around the issue of not
changing the current system. Yet, I've heard few people, providers,
patients, or payors, express satisfaction with what we have. With an
eye to tweaking the hospitalist model in routine inpatient care by
adding a seasoned physician as team ladder increasing quality of
care, reducing costs, and promoting positive patient outcomes looks
easy to achieve. Bring on the ideas from people who think about the
systems they work with; this is where we can get to the outcomes of
the Affordable Care Act without selling our soul to the
bean-counters.
