In her column at the Washington Post Megan McArdle sings the praises of the Cleveland Clinic’s “patient-centered” model of health care delivery and urges Democrats to devote more attention to health care delivery rather than just focusing on payment:
If you offered sick people a choice between reforming the payment side of the system so that everything functions more like Medicare, or reforming the delivery side so that all hospitals function more like the Cleveland Clinic or Kaiser, they might well choose to reform the delivery side. Medical bills are scary, of course, but so is navigating through the fractured mazes of different systems that most very sick people end up caught between — in which vulnerable patients often feel like a lost package, or else an industrial input. So it’s worth asking why Democratic politicians — like too many health systems — seem so relentlessly focused on the money rather than the patients.
One answer is that reforming delivery systems is hard. The government can’t command other health systems to replicate the cultural values, or the institutional expertise, of a Kaiser Permanente or a Cleveland Clinic or a Mayo Clinic. All the government can do is alter payment schedules. And when the Obama administration tried to use that financial lever, it turned out that in the absence of a better institutional culture, patients saw, at best, marginal improvements. At worst, the results were perverse: New Medicare rules that penalized hospital readmissions seem to have resulted in the deaths of some patients.
Unfortunately, if Democrats aren’t going to reform the delivery system, then they probably can’t reform the payment system, either. Because unless America gets a handle on how patients are cared for, we can’t care for millions more of them at a price the American taxpayer will accept.
The phrase “the willing suspension of disbelief”, originally coined by the poet Samuel Taylor Coleridge, refers to Aristotle’s theory of the drama in which the viewer allows him- or herself to accept fiction as reality to experience a catharsis, an overturning of the emotions that brings reality into a different perspective.
Support for Medicare for All requires the willing suspension of disbelief. To accept it as financially, politically, and practically workable you must believe that physicians have lots of slack capacity and will accept a substantial pay cut. I know physicians. I have physicians in my family. I have yet to meet a physician who was not industrious in the extreme. I do not believe that our health care providers have a lot of slack capacity.
I do think that physicians are overpaid for the same reason I think that Chicago teachers are overpaid. The compensation of professionals must remain tethered to the abilities of the communities they serve to pay and both physician pay and that of Chicago teachers have lost that mooring. Despite that belief I do not believe that physicians will accept a pay cut without changing their behavior.
Our current health care providers cannot deliver 3% or 6% or 10% more care. Doing that will require 3% or 6% or 10% more providers. Because of the way health care is actually provided in the United States providing more care may well require a lot more than that. The approaches used by the Cleveland Clinic which include detaching output from physician compensation and a sort of assembly line approach to medicine may well allow more care to be provided without increasing costs but I don’t believe that will be enough.
That will require much more drastic changes including changes of attitude on the part of both providers and patients and changing attitudes is something very hard to effect. Accepting that will take place without dire necessity would require a willing suspension of disbelief on my part.
Just some points. The extreme specialization they tout has lead to better outcomes in some areas, but not everywhere (and what you also want to look at is overall outcomes just not those of specific groups of patients). The only way you achieve that is by having very large hospitals, or systems. Patients will need to be willing to travel long distances. (I am sure I must have recounted here the numerous times I have tried to get patients to go to our main hospital rather than have care at the tiny local hospital and have them refuse.) It also causes issues with night time and emergency cases. Again, if you are big enough you can sort of overcome that, but you have to be really big.
Still, surprisingly, there is some truth in what she writes. The old fee for service system has issues and the kind of hospital structure that results in every specialty and service in silos that dont very well with others costs more and probably does have worse outcomes. There has been too much catering to the whims of certain kinds of physicians that result in that system, plus it works well for administrators. (Again, since I live this every day just an example. Not too long ago when meeting with the finance team I made a suggestion that we adopt a plan I had been working on that would save the entire network a couple million dollars. Finance thought it sounded good but they pointed out they had no viable way to pay my team since everything needs a cost center and cost centers were based in individual hospitals. No individual hospital (CEO) wanted to bear all of the costs, even though it would save money overall for the entire network. Eye opening. Happy to say we got that fixed.) However, all that said, a lot of places, not just Cleveland Clinic are working on this.
As far as the pt experience, at many places it is so fractured that it is miserable. Any hospital/network that is not working on that is a loser. It is a constant effort to make this work better at our place.
Finally, you are correct about doing 5%-10% more work if docs keep thinking the same way and doing stuff the same. We need to find ways to do more without necessarily hiring more docs, ie increase productivity. Use more mid-levels (NPs, PAs, Techs, whatever), make better use of IT. Just better scheduling alone would help. (Did you know that some universities offer sub majors in hospital scheduling? Lehigh University bases theirs in the engineering department.)
Finally, since what i am writing is more than you did, sort of a faux pas, I dont especially want government to tell us how to improve delivery. Just set goals and standards and let us figure it out. Set fee schedules and let the losers fail.
Steve
That occurred to me.
That is something that rarely occurs to planners. What is done in a bureaucracy has more to do with what’s easy to administer than what is effective or furthers the notional goals of the organization. And once organizations reach a certain size, bureaucracy is inevitable. Makes no difference whether it is a government, a hospital, or a private corporation.
The solution to that problem is smallness. In reality bigger is very rarely better. Economies of scale are typically fully realized at much smaller sizes than is usually claimed.
That alone requires a major change in physician attitudes. Not to mention legal changes.
As to scheduling, a submajor in hospital scheduling is an utter waste of time. Scheduling is a task that computer programs are so much better at than humans there is simply no comparison. The main impediment is not being willing to relinquish control.
There are solutions to that problem. Just to cite one example, the largest hospital could take it over and charge the others for it, making a small profit. All of the incentives are aligned correctly. The barriers to that are probably legal.
“That alone requires a major change in physician attitudes. Not to mention legal changes.”
Mostly attitudes. There would need to be some legal changes, but if you change attitudes that would also make the legal changes easier also. We spent some time researching this in our specialty and were able to make use of mid levels in ways not many people use them. Saved a bit of money, though not as much as we hoped. The mid levels expect to eat lunch, get breaks, only work 40 hour weeks, get paid extra on weekends or holidays, etc, none of which I have to do for a doc. Still, in specific areas we save a lot.
” The barriers to that are probably legal.”
I was told it was more accounting and finance related, though for some things it needs to be put into a contract and it was difficult to do so maybe that counts as legal. Anyway, we just created a network cost center. Seems to work so far.
” what’s easy to administer than what is effective or furthers the notional goals of the organization”
Almost all of the incentives for administrators in our network had been oriented towards success in their own particular silo. We finally realized a few years ago that wasn’t good, so now there are more incentives aligned towards network success. It is still difficult as administrators work directly with people in their silo and the network is this amorphous thing. Getting there though I think. My immediate boss is the senior VP of cutting across all of these silos. We were residents together and he really has that “vision thing” plus really good people skills and strong decision making.
Steve