Dr. Brent James Healthcare Reform
Remember the landmark Atul Gawande article about healthcare providers disregarding the costs of tests and procedures, leading to more medicine, not better medicine? This article takes that idea as a given, and offers some practical solutions, still in testing: If Health Care Is Going to Change, Dr. Brent James’s Ideas Will Change It:
As Toyota built better cars than its competition for less money, it won new customers. Some rivals matched its successes (as Honda did); some lost market share (as Detroit did). No such dynamic exists in health care. William Lewis, a former director of the McKinsey Global Institute who studies productivity, says that the economic benefits from the various quality movements have been quite large but that they are also largely in the past. Most industries have incorporated Deming’s big ideas and are now making only incremental progress. “However, there is one big exception,” Lewis adds. “You guessed it: health care.”
Why? In part, it is the faith that patients have in their doctors. When people are buying a car, they often consult Consumer Reports or Road & Track. When they are choosing a place to have surgery, they ask their doctor to recommend a surgeon and go to the hospital where that surgeon works. Hospitals that provide less than top-quality care are rarely punished in the way that General Motors and Ford have been.
So, there’s no impetus for quality improvement. On top of that, when doctors must deviate from routine, they end up administering a battery of tests, which can increase costs dramatically. What’s the solution?
Reform theory
The basic idea of Dr. Brent Jame’s reform is most effective in these situations where doctors would normally run a bunch of tests — by establishing an exhaustive catalog of baselines for treatment (doses, protocols, equipment settings, et al.), the costs of treating patients becomes simultaneously lower and more effective. For example: inductions before 39 weeks of pregnancy were reduced from 30% to 2% of deliveries — evidence went against conventional practice, changed the flawed practice, and resulted in far fewer babies in intensive care.
Fee for health system
Wouldn’t such an obvious beneficial change be quickly adopted around the country? Not if it doesn’t make financial sense:
As long as doctors and hospitals are paid for each extra test and treatment, they will err on the side of more care and not always better care. No doctor or no single hospital can change that. It requires action by the government.
As articulated by this article, the solution becomes tricky in practice: let’s say you try to control costs by bundling — a set fee for different diseases/illnesses. BUT, this gives the hospital an incentive to turn away the sickest patients. The article’s response to this? “Medicare or private hospital groups would most likely monitor outcomes to make sure the incentives didn’t lead hospitals to skimp on care or turn away the sickest patients.” I don’t think the solution lies in more regulation, but instead in building a system with some inherent checks and balances. I do not know how that could be done.
As the article states, “…the only sensible strategy is to try anything that seems promising.”