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?

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.”