• How a health care efficiency revolution could make the next century even greater than the last

    Last week I illustrated how the last century was quite a good one for health. This is largely due to advances in public health, though there is at least one bright spot in the area of medical science: the treatment of cardiovascular disease. There are a few other bright spots too; along with cardiovascular treatments, David Cutler points to early life care and mental health treatment as exemplars. Over the last 50 years, however, whatever advancement has been achieved by medical science, it has come at a very high cost. It would be hard to call the field “efficient.”

    Phillip Longman makes that point in Best Care Anywhere, a quick read covering a great deal of territory.

    According to Harvard health-care economist David M. Cutler, in 1960 the average American 65 or older consumed an inflation-adjusted $11,495 in health care during his or her remaining lifetime. By 2000, that number had jumped to $147,054. Yet despite this elevenfold increase in health-care spending per senior, the resulting gain in life expectancy was a mere 1.7 years. Measured by its “rate of return,” or the extra years of human life produced per health-care dollar spent, American medicine is amazingly unproductive and inefficient.

    Why such inefficiency? In large part that’s what Longman’s book is about. Focusing on the minority of patients accounting for the majority of cost, he writes,

    Medical textbooks are silent about what constitutes appropriate care for patients with many different illnesses, particularly for those nearing the end of life. For example, medical textbooks offer no evidence-based clinical guidelines for how often doctors should schedule such patients for return visits, when they should be hospitalized or admitted to intensive care, or what palliative care they should receive. Nor do medical textbooks offer clear guidelines, grounded in science, about when a doctor should refer a patient suffering from a specific condition to a specialist, much less when it is appropriate to order a diagnostic or imaging test.

    The questions of whether and how physicians might enhance delivery of more efficient care were raised to high profile by the inclusion of the following in the updated edition of the American College of Physicians’ (ACPs’) ethics manual (pdf):

    Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available. […]

    Physicians, patient advocates, insurers, and payers […] should base allocations on medical need, efficacy, cost-effectiveness, and proper distribution of benefits and burdens in society.

    Aaron appropriately pushed back against the notion that the physician’s office is the right place for cost-effectiveness to enter the equation, though it is not clear that’s what the ACP intended. (It is clear it could be read, or misinterpreted, that way.) In a brief and incisive post, Bill Gardner interpreted the ACPs’ call for “parsimonious” care in the context of scarce resources and a goal of universal coverage.

    But if you want limits on spending, and you want at least an approximation of universal coverage, then you need a technological and organizational revolution in health care that will increase the productivity of the medical workforce and reduce the price of good care. And I have a kind of blind faith that this will happen. But until that year of jubilee, we have to accept that insurance cannot cover everything.

    Actually, in large part, that’s what the jubilee would be: guidance about what should and should not be covered with collective (public or premium-based) funds. (Or, in more nuanced form, what value-based insurance looks like in detail.) Naturally, when insurance stops covering things that don’t work (or for whom they don’t work), as demonstrated by sound research, physicians will do less of those things and more of the things we should want them to do, providing more effective and efficient care. That’s the source of higher productivity we’re waiting for. In with the good, out with the bad.

    But, before we have any right to faith in a forthcoming jubilee, we need the research. In JAMA, Vinay Prasad, Adam Cifu, and John Ioannidis say we’re not getting it, even when we try.

    There are thousands of clinical trials, but most deal with trivialities or efforts to buttress the sales of specific products. […] The research community performs studies of modest incremental value without even knowing whether the basic standards of care are appropriate.

    This is an important, systemic failure because, as Prasad, Cifu, and Ioannidis write,

    First, patients who undergo the therapy during the years [untested and inappropriate, yet standard, care] is in favor receive all the risk of treatment and, ultimately, no real benefit. Second, contradicting studies do not immediately force a change in practice; the contradicted practice continues for years. Third, contradiction of mainstream practices undermines trust in the medical system.

    It’s hard not to despair. Much of our efforts in medical care and even well-meaning (or not) medical research are squandered, or, if not quite that, then not directed at the lowest hanging fruit. We don’t just lack the right research, we seem to lack the right research agenda or framework that guides us to that fruit. At the same time, it’s not evident to me we can’t know where to look for that fruit or, at least, narrow the possibilities. I’ll come back to this idea.

    For now, the upside is that there are loads of ways to make the US health system more efficient, even though we may not be able to identify them all right now. By ceasing to make the type of systemic errors described above — by shifting from an eminence based to an evidence based system of care — we can do better. Thanks to investments in public health and a few veins of evidence-based medicine, the last century was quite good despite the systemic errors made in the medical science enterprise. The next could be better still, but only if we change our ways.


    • This is good stuff!
      It’s back to the rule of diminishing returns–at first a little effort gives big results, but after a while, it takes more and more effort (or cost, in some cases) to get very little return.

      We need to put some reason back into American health care, either by “rationing”, or by requiring patients to pay more of the cost, and I recommend that be by cost/benefit analysis.

    • In the US, the financing of health care has focused our attention on “accretive innovation,” where we layer on new processes and technology to allow for higher provider revenue. We generally eschew “disruptive innovation,” which initially delivers inferior products at a much lower price, and ultimately increases overall value in health care delivery.

      I’ve been thinking a lot about Adam Davidson’s article on manufacturing in South Carolina in this month’s Atlantic Magazine. (http://www.theatlantic.com/magazine/archive/2012/01/making-it-in-america/8844/) Standard Motor Products is forced to deliver products of very high quality for costs that are only a bit more than the production cost in China or Poland or Brazil. The company has to practice iron discipline to constrain resource cost or it will go out of business. That discipline is rare in the US medical system.

      There are a series of reasons why there will be more cost pressures and more disruptive innovation in health care in the US over the coming years – which would justify Austin’s optimistic headline.
      1) Affordable Care Act requires and funds more comparative effectiveness research.
      2) Increase in high deductible health plans – which increases “shopping” for lower cost services. Of course, this cuts two ways, since many Americans will be underinsured.
      3) Greater transparency – some forced by companies such as Castlight and some forced through state all-payer databases
      4) Increase in narrow or tiered networks where providers (mostly hospitals) gain a competitive advantage if they can offer sustainable lower prices.
      5) Greater acceptance of virtual visits and non-visit communications- which are time-conserving for patients and allow greater flexibility of medical staffing

      The current model of layering on more and more costs is simply unsustainable – so we should expect it to be disrupted.

      • Excellent comment. I could debate some of the items in your list, but I do not want to. Let’s consider this a brainstorming session, and in that spirit, here are other (potential) productivity-enhancements on the horizon:

        6.) Better understanding and management of patients with complex, chronic conditions.
        7.) Leveraging of health IT both for diagnosis, delivery, and research.
        8.) Increased patient education.
        9.) Greater transparency not just of health services but of insurance.
        10.) Accountable care organizations or the increase in care continuity in general.
        11.) Greater insurance for and provision of effective, under-utilized health services and treatments.

        I do not believe for a second we’re on the right path for many of these, but they all have some theoretical potential. What else?

        • 12) Cultural acceptance of Hospice care/End of life directives
          13) Increase in “lower tier” providers like PAs, NPs, retail clinics and the like
          14) The transformation of medicare as it stands into an ACA like model bringing parity between differently aged populations (e.g., Wyden/Ryan)
          15) Public access to medical blogs, tweets and journals combined with Creative Commons licensing in medical research.

          • Oh yeah, one more:

            16) The added emphasis on systems competency in medical care, as opposed to personnel competency.

            (For more on this, please see: Fixing Healthcare from the Inside: Teaching Residents to Heal Broken Delivery Processes As They Heal Sick Patients by Steven J. Spear )

    • http://www.ncbi.nlm.nih.gov/pubmed/17001126

      Ooops, I forgot the internet mantra:

      No link = no one actually goes to it.