Knowledge is power

I’ll never tire of watching Schoolhouse Rock!

As a kid in the 1970s, I looked forward to each episode as much, if not more so, than the Saturday morning cartoons that surrounded them… with my parents taking in a few in between the chores that I would soon partake in as well. With a budding interest in math and science, these short three-minute videos were effective enough to this author that not only do I remember the topics decades later, but can readily recite them to unfortunate ears on chosen long distance bike rides.

How does this relate to health care? Recently, there has been some excellent discourse on how to heighten the diffusion of health services research into public policy. This author strongly supports the concepts of these postings, but believes an additional approach would be necessary to ultimately fulfill the constructs of bolstering public policy – that of promoting health literacy and health services research to the public in such a manner which would transcend and span generations.

This is where the Schoolhouse Rock! concept would come into play. The method of employing cartoons or videos to inform on health care concepts is not a novel one. In order to nudge public health knowledge and healthy behaviors, Schoolhouse Rock!-esque creations could encapsulate general health literacy notions and health services research outcomes in an amusing, self-promoting and efficacious format which could be easily digestible to children and adults alike. Perhaps even a follow-up album of such health care related topics could be produced with additional artists of the day.

The approach to encouraging healthy behaviors and fostering health services research need not be limited to animation shorts. Recently at the University of Louisville, an all-day symposium was hosted on “Crossing the Divide: On the Adventure of Getting Science Across to the Public”. One of the esteemed speakers was Paul Zaloom, the host of Beakman’s World. Did this show empower both the host and the viewing public in cultivating an interest in science? Well, I will let his quotes answer that principal question.

Equipping the public in this manner could create a cultural and national momentum of health that would advance its own cause… and remember, “It’s great to learn, ‘cause knowledge is power”.

The line between radicalism and realism in healthcare

Is it possible to be too radical in one’s thinking when it comes to changing healthcare? I guess with most things there is likely a fine line. Let’s dissect our words for a second:

rad·i·cal

adj \ˈra-di-kəl\

3a : very different from the usual or traditional : extreme b : favoring extreme changes in existing views, habits, conditions, or institutions c : associated with political views, practices, and policies of extreme change d : advocating extreme measures to retain or restore a political state of affairs <the radical right>

re·al·ism

noun \ˈrē-ə-ˌli-zəm\

1: concern for fact or reality and rejection of the impractical and visionary

Breaking from the usual tradition in healthcare is not a rare thing. In fact, we see this happening more and more in our communities.

In an excellent series on innovation in healthcare, the Harvard Business Review wrote a story on “Radically rethinking healthcare delivery”. An excerpt from that piece really spoke to why radical thinking in redesigning healthcare was appropriate:

“What we describe as a “health care system” is no system at all. It’s a collection of fragmented, non-communicating parts, implicitly dangerous in design. During an average four day hospital stay, a patient sees 24 different clinicians and administrators; when a physician places an order for medications in a hospital, there are seventeen steps between when that order is given and when the medication reaches the patient’s bedside – all opportunities for error. And this complexity happens within a single health care delivery organization. When multiple physicians, clinics, hospitals – and insurance companies – are involved in the care of a patient, the complexity can be overwhelming, both for the patient and clinicians.”

 

Everywhere we look in healthcare there seems to be opportunities for radical change. When electronic medical records rolled on to the scene, they were viewed as disruptive and radical. Now look at where we are with the adoption of these tools. One needs to look no further than the wonderful website and resource put out by AHRQ on innovations in healthcare. But the question remains – are these ideas radical?

For a moment let’s compare healthcare and radicalism to a biological system.

Biological systems function smoothly in homeostasis – they are self regulating and static. Frequently something perturbs that biological system, throws it out of homeostasis, and creates an imbalance. While homeostasis most often is used to describe biological creatures, the message is applicable to healthcare.

When someone in the healthcare system identifies a threat, a perturbation, and attempts to reset to achieve homeostasis, or a balance (read status quo), they “fight” the change. Active perturbation is not comfortable if you are the person being disrupted. Radicalism in healthcare often is disruptive.

Now consider making a change in healthcare on level with a perturbation that is so strong it forces change. Is it possible to have this change be so significant that in essence it creates a new balance, a new baseline for homeostasis?

“Supposedly, everyone working in health care wants the same thing: to help people get and stay healthy. “Everyone” includes primary care doctors, medical specialists, nurses, hospital administrators, health insurance providers, nutritionists, pharmaceutical companies, medical technology manufacturers, fitness gurus, paraprofessionals, public health commissioners, and charities dedicated to a disease The problem is that everyone can have a different view of the meaning of getting and staying healthy. Lack of consensus among players in a complex system is one of the biggest barriers to innovation. One subgroup’s innovation is another subgroup’s loss of control.”

The above quote is another piece from the Harvard Business Review and really hits the nail on the head for radical change in healthcare – for healthcare to change, one “subgroup” will need to lose control. Not everyone can be a winner when you are redesigning a system like healthcare, someone is bound to lose. The problem now, with the current system, is that it is often the community that loses.

Isn’t it time we start to think slightly more radical in how we can redesign healthcare? Do we want to incrementally play it safe through a piecemeal approach to redesign? Are we bound by realism and therefore unable to be radical? Where is the line?

After all, the IOM said it best: “the healthcare system is incapable of meeting the present, let alone future needs of the American public”

What do we really have to lose through being radical that we haven’t already lost?

Money matters

In a recent Harvard Business Review article on solving the cost crisis in healthcare, the following was written:

“Making matters worse, participants in the health care system do not even agree on what they mean by costs. When politicians and policy makers talk about cost reduction and “bending the cost curve,” they are typically referring to how much the government or insurers pay to providers—not to the costs incurred by providers to deliver health care services. Cutting payor reimbursement does reduce the bill paid by insurers and lowers providers’ revenues, but it does nothing to reduce the actual costs of delivering care. Providers share in this confusion. They often allocate their costs to procedures, departments, and services based not on the actual resources used to deliver care but on how much they are reimbursed. But reimbursement itself is based on arbitrary and inaccurate assumptions about the intensity of care.”

Wow.

Let’s take this issue of money and cost a bit further.

A write up from the New York Times summarizes the recent release of the 2011 Employer Health Benefits Annual Survey conducted by the Kaiser Family Foundation.

“…the average annual premium for family coverage through an employer reached $15,073 in 2011, an increase of 9 percent over the previous year.”

Yes, the cost of healthcare, no matter how you define it, continues to rise. Often the public must take on these additional costs as purchasers of health insurance like employers are running out of places to find the money to pay for this benefit. So despite the inability for “participants” in healthcare to agree on what cost means, the community continues to struggle.

And the scariest part – what happens if nothing changes? What happens if healthcare costs continue to rise?

Consider the following graph from the Robert Graham Center and is an example of what could happen:

Essentially this graph shows that by the year 2025 the annual household income in the US will be surpassed by the average health insurance premiums.

They conclude: “Shifting health care coverage from a commodity to a social good could reduce disparities and produce better population health. Changes in health care coverage will require more equitable and sustainable models of health care delivery and aligned advocacy to support them. The instability of health care financing and delivery provides an opportunity for family physician leaders to develop new models of efficient practice, with care that is accessible to everyone.”

So in the face of statistics like the ones mentioned above, how will we respond? Healthcare expenditures and premiums are growing at an uncontrollable rate. When cells do this we call it cancer – when healthcare does this, what do we call it?

Now is the time to start to demonstrate that there are indeed innovative models of healthcare that are out there that can bend the cost curve, improve quality and enhance overall healthcare. Where are they? What are they?

So no matter which way you look at healthcare, the money is a big deal.

How can we begin to change this? One thing is clear – we must.

Back to the Harvard Business Review for one recommendation:

“Accurately measuring costs and outcomes is the single most powerful lever we have today for transforming the economics of health care. As health care leaders obtain more accurate and appropriate costing numbers, they can make bold and politically difficult decisions to lower costs while sustaining or improving outcomes”

Unfortunately no matter how you cut it in healthcare, a lot of the change talk comes down to money. So what are we (you) going to do about it?

Where is the wildfire?

One of the amazing aspects to the occupy Wall Street movement is the spread. The movement has gone from a few on Wall Street to thousands in other cities nationally. As of yesterday, the Occupy Wall Street movement is in 25 cities. A gentleman on NPR recently described the movement like “wildfire”. Granted, there are just as many reasons why a movement like this can gain traction and momentum as there are reasons why movements like this lose traction.

Phil Baumann, in a recent piece on the Unthinkery site, said the following:

“We must understand – at least metaphorically – the half-lives of revolutions. The better we understand them, the better equipped we shall be in their formation, direction and sustenance. The questions are: Where is it coming from?; What’s its energy?; Whereto does it hither?; and What will be the sources of its nourishment? Most importantly: how do we prevent the fate of many revolutions – the all too often disaster of one tyranny replaced by an even more harrowing dystopia?”

Phil is spot on with this one. How well do we, the community, understand what is happening in healthcare?

Community can be defined in so many different ways that for simplicities sake I find it easiest for my work to place community into the following categories: Patient, provider, payer and policy maker. (And yes, I do recognize that it is entirely possible to be more than one of these “categories.”)

It is often said that knowledge alone is not indicative of change. No matter who you are introducing knowledge to, there still must be an attitudinal shift and subsequent behavior change for that knowledge to have had an impact.

Some have written extensively of the role of emotion in change. Without going into all the psychological literature here, let me direct you to a very nicely written Fast Company piece from this past January.

“Knowledge is rarely enough to spark change. People have to want change. Say it’s your job to lure companies to set up shop in Detroit.”

Bringing this full circle, will any attempts to change healthcare fall short as the larger community does not want change?  Does the larger community understand what is happening in healthcare, or are we going to continue to ““periodically kick the responsibility for healthcare down the road”? (quote attributed to TR Reid – posted on this site by Dr. Frank Reed)

If we are to sustain revolution and work towards substantive change, we must believe it is important. Phil is right, too many movements lose steam and putter out. So how do we make healthcare more important to the community to want to change?

If we fall back on the health behavior change literature, we know that:

“Studies have also shown that [health behavior] goals are easier to reach if they’re specific (“I’ll walk 20 minutes a day,” rather than “I’ll get more exercise”) and not too numerous (having too many goals limits the amount of attention and willpower you can devote to reaching any single goal). Another recurring theme is that it’s not enough to have a goal: You also need practical ways to reach it. For example, if your goal is to stick to a low-calorie diet, have a plan in place for quelling hunger pangs (for example, keep a bottle of water or cup of tea nearby, or chew sugarless gum).”

Changing healthcare must start with specific changes. What is the “biggest bang for the buck” that we can get?

Changing healthcare must be important to those making the change – this includes each member of the “community”. They all have to want it.

We all have to want it.

Maybe once we have collectively recognized the importance of changing healthcare we will change it.

…and the change will be like wildfire.

Welcome to the world of workaround

Healthcare is full of examples where clinicians on the ground try to do good quality care, but inevitably are faced with barriers. This is the world of workaround. It is a world where common sense is often not encouraged, and in fact some cases discouraged. It is a world where attempts to do the right thing are met with barriers that have to be overcome in order to achieve the desired outcome. It is a world where we often work harder and get less.

From Wikipedia: “A workaround is a bypass of a recognized problem in a system. A workaround is typically a temporary fix that implies that a genuine solution to the problem is needed. Frequently workarounds are as creative as true solutions, involving outside the box thinking in their creation.”

Or an even better definition by Kobayashi: “informal temporary practices for handling exceptions to normal work flow” (pp. 1561)

Let’s take the issue of efficiency in healthcare to highlight workarounds. In an interesting and thought proving piece, Alan Garber and Jonathan Skinner discuss the inefficiency of the American healthcare system.

From a Health Economist post: “Economists generally define efficiency in two manners: productive efficiency and allocative efficiency.  Productive efficiency means producing a good or service using fewest inputs.  A car company who produces a car that costs $20,000 to manufacture is less efficient than a company that can produce that same car (at the same quality) at a cost of $15,000.  Allocative efficiency is more subtle.  Are we producing the right amount of cars compared to trucks?  As gas prices rose, allocative efficiency compelled many car makers to shift to smaller passenger cars and hybrids compared to trucks.”

Consider the following opening lines from the Garber and Skinner paper: “Although countries around the world are grappling with the problem of rising health expenditures, the U.S. has reason for particular concern. Americans are dissatisfied with their health care system (Schoen, et. al., 2007) but also spend more than the citizens of other nations: 15 percent of GDP on health care in 2006, compared to 11 percent in France and Germany, 10 percent in Canada, and 8 percent in the United Kingdom and Japan (OECD, 2008).”

It is impossible to have a conversation on workarounds and healthcare inefficiency without discussing the amount of money the US healthcare system spends. The Kaiser Family Foundation has some excellent resources on healthcare spending. Take for example the graph seen here. “ Health spending per capita in the United States is much higher than in other countries – at least $2,535 dollars, or 51%, higher than Norway, the next largest per capita spender. Furthermore, the United States spends nearly double the average $3,923 for the 15 countries.”

So we spend more money and are not too happy about the care we receive?

Now, back to the workarounds.

There are studies that show the more time a healthcare provider (nurses in this case), the better the patient health outcomes. Yet despite providers and patients preferring more time with one another, there exists a system that forces them to see each other in short periods of time. To remedy this problem, providers often come up with interesting workarounds to spend more time with their patients. Since the system rewards volume over outcomes, workarounds often become one of more interesting challenges to allow for providers to spend more time with their patients.

Garber and Skinner conclude: “Perhaps the greatest hope for improving both allocative and productive efficiency will come from efforts to measure and reward accurately outcome productivity – improving health outcomes using cost-effective management of diseases – rather than rewarding on basis of unit service productivity for profitable stents, caesarian-sections, and diagnostic imaging regardless of their impact on health outcomes. This will require rethinking what we pay physicians and hospitals for and most importantly how to measure and pay for outcomes rather than inputs.”

And again we come back to the idea that workarounds may not be the most efficient way to deliver healthcare. How can we create a system that is simultaneously efficient and effective? Somehow workarounds don’t seem to be the way to get there.

After all, “slowing health care cost growth, while sustaining and improving quality, will not be easy but is doable.”

Is healthcare too important to fail?

“The U.S. health care delivery system does not provide consistent, high quality medical care to all people. Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge–yet there is strong evidence that this frequently is not the case. Health care harms patients too frequently and routinely fails to deliver its potential benefits. Indeed, between the health care that we now have and the health care that we could have lies not just a gap, but a chasm.” – From the Institute of Medicine’s Crossing the Quality Chasm: A New Health System for the 21st Century

In a recent well thought out blog post, Alex Fair asks the question – is healthcare too important to fail?

He discusses the precarious balance between disrupting healthcare and the ongoing need to preserve the care delivery system so the community can continue to benefit from services. Rightfully so, he outlines two tenants for an Occupy Healthcare movement:

1. Do No Harm, do not disrupt the delivery system

2. We all must Embrace Innovation that Reduces the Cost of Delivering or Receiving Care

However, here is the fundamental question – a question that is at the heart of any and all who are interested in changing healthcare – where do we draw the line between the system and the care delivered? Is it possible? Can we be assured that disrupting the system will never happen if we want to see substantive change?

According the the IOM report, healthcare is failing. And this failing is not small (a gap), it is quite significant (a chasm).

Gawande has an excellent take on healthcare change. From his article in the New Yorker: “Whatever the [healthcare] system’s contours, we will still find it exasperating, even disappointing. We’re not going to get perfection. But we can have transformation—which is to say, a health-care system that works. And there are ways to get there that start from where we are.”

My point here is to tie together both what Alex said in his blog, and what Gawande said in his article – there are ways to transform healthcare, but where is the right level of disruption that pushes us forward, keeping all the good things and preserving pieces of the system that can continue to meet the healthcare need of the community while ridding ourselves of the parts that don’t work?

Often our failing can be attributed to perverse system incentives and demands. Healthcare providers behavior is often dictated by the system. Take for example services recommended by the US Preventive Services Task Force (USPSTF). No doubt these recommendations are important and need to be addressed; however, in a healthcare system that is often driven by time, it is seemingly impossible to do all that is recommended.

Consider the now highly cited Yarnell paper from the American Journal of Public Heath:

“To fully satisfy the USPSTF recommendations, 1773 hours of a physician’s annual time, or 7.4 hours per working day, is needed for the provision of preventive services.”

Bending the cost curve in healthcare requires addressing several things simultaneously. Prevention is one of those things.

Dr. Stephen Shortell in JAMA said it best:

“Disease prevention initiatives aimed at improving nutrition, physical activity, tobacco use, and related lifestyle behaviors are likely to have the greatest effect on slowing the annual increase in health care costs. This is because they have the largest influence on reducing the future burden of disease, particularly in regard to obesity and the sequelae of diabetes, heart disease, and cancer.”

This brings us full circle to what is most important in healthcare. Some argue that financial reform should rule the roost whereby providers do what they are paid to do. Others argue for training and education reform. But in the end, isn’t it the community, the patients who are most important? The system, however flawed it is, remains a fixture by which everyone receives their healthcare. Yes, we will do no harm; and yes, we will embrace innovation, but how we will do that in redesigning this system remains to be seen.

Isn’t it time to cross the chasm for healthcare? Isn’t it time we demand just a bit more? In doing so, healthcare will not fail, it already has.

When will healthcare have its “Occupy Wall Street” moment?

In order to answer this question, let us first define what the occupy wall street movement is about. According to ABC News:

“Their [Occupy Wall Street] causes include everything from global warming to gas prices to corporate greed, and the Occupy Wall Street website says organizers took their inspiration in part from the so-called Arab Spring demonstrations that have tried to bring democracy across the Arab world.

But while their message might be a tad muddled, all are united by their anger over what they say is a broken system, a system that serves the wealthy and powerful at the expense of the rest.

Protester Brendan Burke insists he and the others are fighting for more than 99 percent of the American population.”

Let me highlight one section from above:

“…all are united by their anger over what they say is a broken system…”

Would anyone argue that healthcare is not broken? At the heart of this brokenness lies fragmentation that perpetuates this brokenness.

The question remains, why is the public not more outraged at the broken healthcare system?

While healthcare costs continue to grow uncontrollably, the public continues to suffer. In the face of this suffering, there does not appear to be much relief. Thankfully, the Affordable Care Act does try to mitigate some of these issues (especially cost), but is this sufficient without adequate community “outrage” over healthcare?

As Gawande has written – “In every industrialized nation, the movement to reform health care has begun with stories about cruelty.”

Not to be overly melodramatic here, but one needs look no further than “mental health” to see how the system has often failed folks who have this as their presenting problem. Not to imply that this is cruelty, but when one starts to cite statistics about mortality in the severely mentally ill, there should be some outrage.

There should be a demand from across the community that healthcare should be high quality, affordable and integrated as to avoid fragmentation. Yet where is the demand?

Maybe healthcare has not had it’s “Wall Street” moment because there is no one place the national community can gather to express their outrage. Yes, we advocate in our own unique ways – write letters to our legislators, visit them and on speak up in town hall meetings, but is this sufficient? Even if we had a special street corner to meet to talk about healthcare, would we?

How can we begin to engage the community so that healthcare can have its “Occupy Wall Street” moment? Or, as the Occupy Wall Street movement has shown, where are the select individuals who will rise up and fight for “the 99%”?

Isn’t it time?

This website will be a location where the community can come to discuss healthcare. A place where meaningful healthcare issues can be raised and worked on together.

Now is the time for the Occupy Healthcare movement. Let’s begin.