• Atul Gawande on “Big Medicine” and the rise of chains

    When Aaron showed this chart,

    readers wondered what might be done to reduce costs where it counts, for the minority of patients that account for the majority of health spending. In another gem, Atul Gawande arrives at some answers, by way of analogy to the efficiency of meal production at the Cheesecake Factory.

    The question is whether the medical counterparts to Mauricio at the [Cheesecake Factory] broiler station—the clinicians in the operating rooms, in the medical offices, in the intensive-care units—will go along with the plan. Fixing a nice piece of steak is hardly of the same complexity as diagnosing the cause of an elderly patient’s loss of consciousness. Doctors and patients have not had a positive experience with outsiders second-guessing decisions. How will they feel about managers trying to tell them what the “best practices” are?

    No question, many will detest it and fight it with all their might. But some will not. To what end? Gawande offers a few examples, such as:

    The surgeons now use a single manufacturer for seventy-five per cent of their [knee replacement] 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).

    The whole thing is worth a read. I know it is long, but the part near the end about Steward’s ICU command center is not to be missed.

    For all that, I doubt the shape of the distribution of health spending will change much. The sicker will account for vastly more spending, relative to the healthy, even if it is at an overall lower level than it otherwise would be. That’s as it should be. But if dollars are spent for more efficient care, my guess is that more of us will be satisfied with a greater amount of health spending than we would otherwise. We may reasonably conclude we’re getting a perfectly fine deal, that it is worth the price.

    We should all be for quality and efficiency. Isn’t that what you’d want for yourself in the ICU anyway, even at lower cost and most especially at a high cost?


    • I’ve only been to a Cheesecake Factory once or twice in my life. I was impressed by the copious amounts of mediocre food I got for my money. However, I prefer a smaller amount of tasty, well prepared food.

      Comparing performing surgery to making mediocre food isn’t reassuring to me and I usually love Gawande’s writing.

    • I think our health care system is very hostile to the concept of efficiency. Doctors will not abide by being told how to practice medicine.
      Medical costs do not respond to volume or experience in the way that that the rest of industry does. CAT and MRI scans are still priced as if they were rare experimental procedures run on expensive prototype hardware. Look at cataract surgery. It’s still priced as a difficult procedure requiring supernatural skills, not the routine 10 minute procedure it has become.
      Other countries approach this problem by mandating prices and dictating reimbursement. In the US, we have regulatory capture (health industry buying politicians) which keeps prices high.

    • Geting docs to work with guidelines and follow protocols has been a time consuming chore. I tell people they need to be an even better doc when they use guidelines since they need to know when to deviate. Still get lots of resistance.

      The command center is interesting, but how do they pay for it? I am pretty sure Medicare will not reimburse for this. They will need to show pretty significant savings to make this pay. What was the investment in hardware I have to wonder.


    • The most important point in the article to my mind is that health care as an industry has not made a practice of looking to places that provide better value as models to be emulated. Intermountain, Geisinger, Kaiser, GroupHealth, we all know their names, in part because these places exist in splendid isolation, and persist in large measure not because of market forces, but rather because of culture and tradition. I am less sanguine than Atul that ACOs will prove to be the answer to our cost and quality problem because so many will not have developed the culture of value. (Actually, I don’t think Atul is endorsing ACOs so much as he is making the much-needed point for a general audience that a little consistency and efficiency would be a boon to medicine.) As long as the payment model is fundamental volume based (fee for service) I worry ACOs will turn out to be just another way for many hospitals to gain market share and make more money by providing lots of chaotic, poor quality care.

    • I agree with everyone, including Gawande, who is saying that practice patterns are a cultural issue. It is not an accident that several of the five star rated Medicare Advantage programs that are not large HMO’s are in the Upper Midwest, where the century old “splash pattern” of the Mayo Clinic, an early and ongoing practitioner of the uniform scientifically derived practice pattern, has influenced practitioners and administrators who were trained or heavily effected by Mayo. It is also no accident that the Upper Midwest provides better care for less money in the Dartmouth studies and other similar research. Large HMO’s and other large integrated systems have similar results elsewhere in the country, but less influence due to not being involved in training programs and frequently being seen as the “enemy” by existing training programs in their area. Mayo itself has brought its own culture to the Phoenix area, successfully reproducing its results in its own operation but without influencing the area as a whole. Cleveland Clinic has seen similar results with its outreach projects.

      However, because of rising costs for both private insurance and public insurance programs we are rapidly approaching the point where the failure to learn these lessons becomes a crisis. Rising costs are creating a rivalry between two approaches to dealing with high costs, one based on directly cutting spending by public and private insurers and transferring much of the risk and cost, and potential ill effects on health, to the insured, and the other applying best practice standards as a way of reducing cost while protecting access to care and improving results. Gawande, of course, is a high profile advocate of the second approach, but as he himself has pointed out in this article as well as in others, it is very hard sledding to convince providers and hospitals to abandon less efficient and effective patterns.

    • I agree with Gawande that there can be improvements in efficiency to reduce costs. However, I believe that the “elephant in the room” is doctor and hospital driven overutilization of tests, procedures and treatments of dubious value.
      Today’s NY Times gives a good example with the story of HCA “discovering” that it’s doctors were performing cardiac caths on patients who did not need the procedure. The doctors and hospitals profited, patients suffered and our health care system experienced higher costs (with resultant calls to reduce benefits).
      The rest of the developed world provides better health services to a larger percentage of their population at about half the cost of the US per capita. The US performs far too many dubious tests, procedures and treatments and charges too much for them. This is where to look for real savings.

    • Great article, and great comments. There is also a source of resistance, in that Gawande’s proposed system does indeed reduce a little MD’s status as a kind of priest, instead making them skilled practitioners who are part of a standardized system.
      In a just world, doctors’ pay would drop a bit, flattening out the income curve in the healthcare industry. Those at the top may well resist such a move. Also, there is a cultural drive to worship Mighty Men, and feel that we must give them whatever they ask, or they’ll Go Galt, and we’ll be lost.

    • Austin and Aaron – You may be more interested in Atul Gawande’s article, the Hot Spotters, in the New Yorker, from January 2011. He looks at efforts to address the most expensive patients out there, including health analytics, medical homes, etc.