Ten days ago I returned from Washington DC where I attended the first Care Innovation Summit sponsored by the Center for Medicareand Medicaid Innovation. http://innovations.cms.gov/
I recognize we are living in tough political and economic times. The national debt, unemployment, partisan conflict, struggling schools, and disenfranchised groups all come to mind when I think of serious political concerns. But the problems in the healthcare system feed into many of the larger issues our country is facing. Healthcare as it exists today is destroying American prosperity and the American dream. With 17.9% of the GDP spent on healthcare, it is imperative that we jail break the health care system at a price we can afford. We need to change the system so that value is incentivized over volume (i.e. how many patients are seen, how many tests are ordered, etc.) while keeping the patient’s personal experience at the center of all we do.
For such big problems there are obviously no easy answers. The political gridlock we’ve seen in Washington in recent years contributes to the perception that everyone on Capitol Hill is motivated by personal agendas with little concern for the greater good. But today I want to show you another side of what’s going on in Washington. I want to familiarize my readers with the innovators in this country committed to reforming the healthcare delivery system, fixing the SGR, and reforming the way payments are made to reward quality and innovation.
The list of speakers that I had the privilege of listening to is much too extensive to cover here, so I’m choosing to highlight two amazing voices on the healthcare scene that left the strongest impression on me. The first is Susan Dentzer, the Editor-in-Chief of Health Affairs http://www.healthaffairs.org/ which is the nation’s leading peer-reviewed journal focused on the intersection of health, health care and health policy in the US and internationally. Susan used the words of the renowned writer from Stanford’s MBA school, Jim Collins, to talk about how we need a healthcare system that is built to last.1
America is full of many corporate successes. This is because our capitalist culture generously rewards true innovation that is successfully implemented. Financial incentive encourages risk takers with boundless optimism and extraordinary creativity to come up with solutions to some of our toughest problems. This drive to innovate is rooted in the American spirit. Susan Dentzer pointed out that we need a partnership between the private and public sectors to come up with the best answers for the healthcare crisis. By taking this approach we should be able to step away from the in-fighting in Washington because “innovation is not a partisan issue. It comes in purple, not blue or red.”
The second speaker whose words I want to spread is Atul Gawande, MD, MPH who is a surgeon at the Harvard Medical School as well as a writer of three New York Times bestselling books2,3,4 and a public health researcher. Dr. Gawande contrasted the medical system in the pre-penicillin era5 to today’s much more complex environment. One hundred years ago healthcare was cheap, but completely ineffective. Dr. Gawande pointed out that today we have 13,600 unique diagnoses for human diseases, and 6000 different medications we can prescribe or operations we can perform. Per his count we have 13,600 service lines that we are trying to roll out to every person in every community!
Dr. Gawande astutely concludes that the reason healthcare costs are so out of control is that innovations in delivery systems have not kept pace with the scientific and medical discoveries we can now leverage. The old system rewarded the cowboys, physicians who could enter a room, take control, and do it all. But the paradigm of individual clinicians trying to do it all on their own isn’t working. Instead of cowboys, Dr. Gawande eloquently explained that we now need highly effective pit crews where humility, accountability, and self-discipline are what’s valued.
But how do we know if the pit crew is doing a good job or not? How can the struggling crews identify the more effective teams and implement their secrets of success? The answer lies in the ability to capture, analyze and report the DATA!!! Without data we have no ability to recognize success and failure. Dr. Gawande pointed out that at the turn of the century the American people were facing a crisis in the ability to produce and deliver enough food to its citizens. At that point in history 40% of the family budget was going to food costs. To address this serious problem the government collected data in the form of comparative effectiveness research and created regulations and incentives to encourage farmers to use processes that were proven to work. The government also created the national weather service, which provided the farmers with important information to protect their crops. Over the course of 20 years the percentage of the family budget that went towards food dropped from 40% to only 20%. We need to do this in healthcare today.
The widespread adoption of electronic medical record systems (EMRs) by physicians has us on our way, but simply having a system doesn’t mean it’s being used in a way that provides structured data that can be studied. CMS is trying to make this possible by demanding that physicians adopt CCHIT (Certified Commision for Health Information Technology) certified EMRs which use HL7 CCD (Health Level 7 Continuity of Care Document) programming to promote the exchange of health information between providers and facilities involved in a patient’s care. This will lead to a profound reduction in healthcare spending because test results will be accessible, and expensive imaging studies will not need to be repeated. Having access to the patient’s complete medical history will also help physicians to make accurate diagnoses and appropriate treatment plans.
In the words of Dr. Gawande, analyzing the data available to us today is like driving a car with a speedometer that tells us how fast everyone else on the road was going four years ago – not very helpful! He pointed out that we know much more about how the crops and cows are doing in our country than the human beings. We have a big problem in our healthcare system, and it needs to be fixed STAT! Data is the oxygen for innovation, and right now we’re suffocating. I feel strongly that patients should have a universal patient identifier (UPI) so that physicians don’t have to rely on having a conscious patient with a good memory and enough medical knowledge to understand what is or isn’t important regarding their past medical history. I acknowledge that this is a controversial issue, and to see both sides of the story I invite you to read an article in the Wall Street Journal a couple of weeks ago that addresses both sides of the argument. http://online.wsj.com/article/SB20001424052970204124204577154661814932978.html?KEYWORDS=squaring+off+on+health+care
But I agree with Dr. Gawande that if we can’t access data on patient outcomes, it will be impossible to understand our current baseline. Without this basic understanding, we will not be able to identify either problems we can fix in the current system, or opportunities to provide better delivery of healthcare to our citizens. It is difficult if not impossible to set goals for improvement in medical delivery and quality of care without access to relevant and reliable data. We also need data so that after implementing changes we can assess progress and identify teams who achieve superior outcomes at reasonable costs.
I share Dr. Gawande’s belief that we are fighting a war to preserve the soul of American medicine. Regardless of political affiliation we all want people to survive and live their lives to their fullest potential. I came home from Washington imbued with hope that if the citizens, the doctors, the innovators, and the politicians work together to capture the data floating around in our current healthcare system, we can achieve the goals of the three part aim – better health, better care, at reduced costs.
1Built to Last: Successful Habits of Visionary Companies, James C. Collins, Jerry I. Porras, 1997 A Harper Business Book
2The Checklist Manifesto, Atul Gawande, 2011, Metropolitan Books
3 Better: A Surgeon’s Notes on Performance, Atul Gawande, 2007 Metropolitan Books
4 Complications: A Surgeon’s Notes on an Imperfect Science, Atul Gawande, 2002 Picador
5The Youngest Science: Notes of a Medicine-Watcher, Lewis Thomas, 1983 Penguin Books