Is health care corrupted?

Recently in the New York Times I saw an invited editorial by Pamela Hartzband (a Boston Physician) and her husband Jerome Groopman (a Boston physician who wrote How Doctors Think). The editorial was entitled How Medical Care is Being Corrupted (

Drs. Hartzband and Groopman assert that pay for performance is not good for health care because it will incentivize physicians not to do what’s in the best interest of their patients.  Of course, incentivizing can lead to unintended consequences, but I would assert that our current fee-for-service system has more damaging consequences.

A few days later my former health care policy teacher wrote about this op-ed in his blog ( He wasn’t impressed either.  He felt that the perfect way to compensate physicians doesn’t exist, and not holding physicians accountable for providing evidence-based care isn’t a good idea.  In addition we need to hold systems accountable for not causing unnecessary harm.

Are they suggesting that fee for service is better? And hasn’t created corruption?   Mmmm…

Current pay for performance formulas and strategies are far from perfect. The triple aim in its simplified version contains a paradox for sure – better population health and better care for the individual patient? What? And add better cost to that and you get a triple paradox, especially when you consider that no one in health care wants to be paid less.

Could pay for performance lead to gaming of the system and undesirable behaviors? Probably. Would it be worse than what we have now? Probably not.

Hasn’t the current reimbursement system led to poor quality, unreliable safety, overuse, misuse and underuse? Haven’t physicians made decisions about what kind of medicine to practice, where to practice, what kind of patients to care for and what to do for those patients based on our current fee for service reimbursement? Don’t we essentially have a corrupt health care system now?  Perhaps I’m being too negative, but the Hartzband-Groopman op-ed by not addressing these questions at least a little lacks some credibility.

Physicians have often elevated themselves to a mystical high road, creating a façade of selflessness and high morality. Drs Groopman and Hartzband have only repeated this cliché in their op-ed. The reality is that physicians have repeatedly demonstrated that they are merely human and their motivations are prone to selfishness.  In fact, their op-ed suggests this.  Physicians’ decisions ought to be centered on the needs and goals of the patient and evidence-based.  We could add the needs of the community and population as well.  They need to be fairly rewarded for doing their job well and for the quantity at which they do it.  Balance is the key.

Who’s on first, What’s on second and I don’t know who’s on third

Who’s on first? – Is it the patient?  The doctor?  The hospital?  The payer? In our everyday clinical (and non-clinical) practice we need to remind ourselves it’s the patient. When the patient is first, safety is first, quality is first, the care experience is first, and access is first.  Soon cost will be more of a consideration as individuals become increasingly responsible for the cost.

What’s on second? – If the patient’s on first, then what’s on second? Is it the doctor? The hospital? The payer?   It must be one of those, right? Wrong. Knowledge, information, and data are on second. It’s a huge “What” in health care and we’re not so good at managing, using and communicating it.  We simply have to get better at it. It will take technology and its proper application to disrupt our current system. There is good news.  We’re on the early part of the slope.

I don’t know who’s on third – Yes, we often don’t know and it’s a problem.  Once again, it’s not the doctors, the payers or the hospitals.  Culture is on third.  Culture defines and drives performance. And most of us don’t know much about it or how to influence it, let alone manage it. Culture is the end result of the behaviors, processes, strategies, values and visions put forth by leadership.  Its the driver of organizational behavior.  And culture is really what you are trying to influence when you make decisions and act as a leader. Putting in place a new process isn’t in of itself going to do much. Its what it does to the culture that really matters in the long run.

Baseball as a metaphor: Health care delivery is a team sport, and each position must be played well for the team to win. The physician, although not “on first” is certainly in the position of being captain, or at least the pitcher. The catcher is the advanced practitioner or nurse who helps manage the patients. And there are others on the team that the patient relies on.  Increasingly we are using medical assistants to assist us in collecting data, navigating patients and monitoring adherence.  The culture of the team is as important as the competence of each individual. We’ve seen that play out in major league sports time and time again.

So, what’s the secret sauce for creating a strong culture of excellence and reliability in health care? The evidence would suggest that its leadership.  I recently suggested in our organization that we have a leadership credo for our clinical transformation initiative. Someone on the work group asked why.  A fair question.  The reason is because leadership sets the tone, it’s the key to culture. If the leaders aren’t consistent, reliable, mindful, committed to transformation, committed to our chosen improvement tools, and committed to culture shift, then the effort fails. If we aren’t all rowing in the same direction as leaders, then the effort fails.

What’s your leadership credo?  And does each person on your leadership team share and live the same credo?

What not to do to cut health care costs

In this month’s Harvard Business Review (November 2014) there’s an article by Robert Kaplan and Derek Haas entitled How Not to Cut Health Care Costs. The authors list 5 common mistakes that health care systems and teams make when trying to lower costs:

  • Cutting back on support staff,
  • Underinvesting in space and equipment,
  • Focusing narrowly on procurement prices,
  • Maximizing patient throughput,
  • Failing to benchmark and standardize.

I can only imagine that some must have been scratching their head while reading this article.

Here is my summary:

#1 Cutting back on staff:   It turns out that support staff aren’t the expense problem and cutting them creates bottlenecks and more work for clinical staff who could instead be directly helping patients instead of doing clerical work, managing schedules, and solving operational problems.

#2 Underinvesting in space and equipment:   Space and equipment can drive up costs if not managed prudently, however, too often these items are cut to the point of creating bottlenecks and wasting more expensive resources (like doctors).

#3 Too much focus on small procurement prices:  It turns out that saving $0.10 on every 100 gauze may be a victory for the supply chain manager, but it does very little for the bottom line. It would be better to reduce the waste of relatively expensive supplies that are common in health care. This is especially true in procedure oriented areas.  And it turns out that the variability in use of these expensive supplies is considerable, suggesting room for improvement.

#4 Maximizing patient throughput:  This is my favorite.  The article asserts that pushing doctors to see more patients, or incentivizing them to see more patients (same thing), leads to increased health care costs , and not just because they will tend to do more than they really need to, but because they aren’t making long-term investments in their patients. An example is talking about advanced directives for people with terminal illnesses, or counseling patients with end stage renal disease who are likely to need dialysis.

#5 Failing to standardize:  Need I say anything further – not taking the time to standardize the processes of care and of doing business (operations) sets a system up for unnecessary variability, confusion, reworks, poor communication, etc.

There is an interesting paragraph towards the end of the article that states: “High health care costs are the result of mismatched capacity, fragmented delivery, suboptimal outcomes and inefficient use of highly skilled clinical and technical staff. The current practice of managing and cutting costs does nothing to address those problems.”

Articles that make you go ummmm…

Redesigning to be Patient & Family-Centered

I recently wrote down some guiding principles for redesigning patient-centered care delivery.  These patient-centered directives are taken from years of reading, hearing and seeing best practices and principles.  I’ve especially been influenced by the speeches and writings of Don Berwick and Bev Johnson.

Here they are:

  • “Don’t harm me”
  • “Don’t unnecessarily disrupt my time, my place, my money, my dignity, my privacy”
  • “Do comfort me and care about me while you care for me”
  • “Do keep me informed in real-time”
  • “Do include me in decision-making”
  • “Do help me manage my illness so I can be and feel healthier”
  • “Nothing for me without me”

Here are some systems-thinking principles to keep in mind:

  • Value streams are mapped through the eyes of the patient and family.
  • Processes are designed to maximize value for the patient and family (and community).
  • What we do is for the patient and family, and how we do it is also for the patient and family.
  • The system is designed with the patient and family as well as for the patient and family
  • The system anticipates the needs of the patient and family
  • The system is flexible and predictable in the eyes of the patient and family
  • The Voice of the Customer is used in every process improvement and redesign

You might recognize that there are 14 points here.  You also might recognize that half of them are directly from the voice of the patient (a lucky seven).  These are powerful and transformative principles when followed relentlessly and deliberately.  I’ve followed these principles to the best of my ability as a physician and a leader and they work.