0 Quality and price for everyone: Bigger may be better in some ways, but not all

Atul Gawande, MD, a Harvard surgeon at Brigham and Women’s Hospital in Boston, regularly contributes significant and provocative articles to the New Yorker under the head “Annals of Medicine”. In recent years I have written about several of these, including the “The Cost Conundrum”, June 1, 2009 (my comments in Medicare Costs: "All Politics are Local", June 11, 2009), “The Hot Spotters”, January 24, 2011 (Freedom abroad, health at home: experiments in preventive health care, February 13, 2011 and Camden and you: the cost of health care to communities, February 18, 2011), and “Cowboys and Pit Crews”,  May 26, 2011 (EMRs and Primary Care: The good, the bad, and the challenges, June 11, 2011 and Physician Oaths and Social Responsibility, July 11, 2011). His latest contribution, “Big Med”, August 13, 2012, continues his outstanding tradition of thinking outside the box, making important connections, and writing for a popular-but-educated audience.

“Big Med” starts with a visit to the popular restaurant chain, The Cheesecake Factory, and proceeds with his investigation into how it works and works effectively. This chain provides an enormous variety of menu choices, high quality both in terms of ingredients and taste (perhaps not the gourmet’s standard, but really good food), excellent consistency, and reasonable prices. It does not take a huge step to understand the relevant metaphors for health care, and in particular hospital care. Hospitals provide a huge menu of services, and we would all like them to be consistently of high quality and available at a reasonable cost. Unfortunately, they’re not. Gawande searches for how The Cheesecake Factory does it, and comes up with some excellent suggestions for health care.

He starts with the key ideas mentioned above: people should be able to go into a hospital and expect the best care and the best possible outcomes. These should be consistently delivered, and delivered at many locations (not necessarily every hospital for every procedure – to extend the analogy, The Cheesecake Factory has lots of restaurants, but not in every town) and done in a cost-effective way. While with restaurants, each of us knows what we like and whether something tastes good and whether we think we have gotten value for our dollar this is not true for health care. Most people (including physicians outside their own specialty) have little idea of what is quality in medicine. They can tell if they had a good outcome (“I’m better”), but not if it was the intervention that made it better, or perhaps just speeded up – or retarded – natural healing. They can tell if they had a bad outcome (or their survivors can), but not if this was unavoidable. (The current method we have for adjudicating this – malpractice suits – is entirely invalid.) They do not know if their outcome would have been better in a different hospital or with a different doctor or team, or even in the same hospital with the same doctor on a different day. They certainly don’t know whether what they, or their insurer, are paying is appropriate for the value.[1]

Gawande writes that “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…We can bristle at the idea of chains and mass production, with their homogeneity, predictability, and constant genuflection to the value-for-money god. Then you spend a bad night in a “quaint” “one of a kind” bed-and-breakfast that turns out to have a manic, halitoxic innkeeper who can’t keep the hot water running, and it’s right back to the Hyatt. Medicine, though, had held out against the trend. 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.”

He goes on to describe examples of how American medical care is changing, focusing on the experience of his mother getting a knee replacement at his hospital by a surgeon (not the most famous) who has organized a standardized system for delivering this care, using a (large) team. This surgeon has also accomplished the remarkable (to anyone who knows surgeons) feat of getting all the prima donna orthopedists at his hospital to agree to use the same prosthesis. The principle, just as in the casual dining area, is find out who does it best, identify the characteristics that make it so (removing the chaff and nonsense that may be associated but are just noise, often costly noise), and replicate it.

Applying this principle requires not only standardization, but size. Every hospital cannot be a mom-and-pop store, and the cost savings from scale are what make the whole thing possible. Yes, medical care cannot be completely reduced to recipes, and this can be a real danger. Individual doctors are different, and their skills are different not only by specialty or subspecialty, but in the way they interact with their patients. Some people may like a doctor who is older, or younger; a doctor who is a woman, or a man; a doctor who is more formal, or more casual. Some want a doctor who will explain things to them and elicit their beliefs and desires, and make them the educated “decider”; others want a doctor who is more didactic and authoritative. None of these is the “best” for someone who does not share those values; each is the “best” for those of us who do. The only caveat is when a particular approach actually makes a difference in the health outcomes for all people, not just those who “like” the doctor’s style.

Another danger in size and scale is that many of the processes and procedures that are put in place by these big, standardized organizations do not improve health outcomes, and may even limit them by taking time and energy from the things that do. Management in health care is still very much tied to “Motivation 2.0” (see “Drive”, by Daniel Pink[2], and my comments in The Primary Care Conundrum, August 18, 2012).  Many big food, or hotel, or hospital chains do not provide quality, and most certainly do not contain costs; see, for example, “A giant hospital chain is blazing a profit trail”, by Julie Creswell and Reed Abelson in the New York Times August 14, 2012, about Hospital Corporation of America (HCA). Like HCA, “big” is not a panacea, and can be a negative for social values and social justice.

Gawande includes important cautions:

"Yet it seems strange to pin our hopes on chains. We have no guarantee that Big Medicine will serve the social good. Whatever the industry, an increase in size and control creates the conditions for monopoly, which could do the opposite of what we want: suppress innovation and drive up costs over time. In the past, certainly, health-care systems that pursued size and market power were better at raising prices than at lowering them….

“The vast savings of Big Medicine could be widely shared-or reserved for a few. The clinicians who are trying to reinvent medicine aren't doing it to make hedge-fund managers and bondholders richer; they want to see that everyone benefits from the savings their work generates-and that won't be automatic….

"Our new models come from industries that have learned to increase the capabilities and efficiency of the human beings who work for them. Yet the same industries have also tended to devalue those employees. The frontline worker, whether he is making cars, solar panels, or wasabi-crusted ahi tuna, now generates unprecedented value but receives little of the wealth he is creating. Can we avoid this as we revolutionize health care?"

I don’t know, but I hope so. Holding on to old ways of doing things when they are not the best (or even very good), or the idea that each doctor can use a different prosthesis and they are all the best, is bad. Devaluing individual workers, whether they are physicians or technicians or cleaners, is bad. Developing ways of delivering high-quality care which is what both individual people and the whole society needs is good.

Good outcomes will certainly not come from the drive to maximize profit. To get truly good outcomes, we must put people and put social justice at the center of any change.

[1] I love this part: Historically, doctors have been paid for services, not results. In the eighteenth century B.C., Hammurabi’s code instructed that a surgeon be paid ten shekels of silver every time he performed a procedure for a patrician—opening an abscess or treating a cataract with his bronze lancet. It also instructed that if the patient should die or lose an eye, the surgeon’s hands be cut off. Apparently, the Mesopotamian surgeons’ lobby got this results clause dropped. Since then, we’ve generally been paid for what we do, whatever happens.”

[2] Pink, Daniel H, “Drive: the surprising truth about what motivates us”, Riverhead Books, New York 2009.

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