The Work-Around
 
            In a recent op-ed in The New York Times,[1] Theresa Brown observed from hiding medications behind ceiling tiles to using scribes to enter data in computers, the US healthcare system has become a giant work-around—sometimes trading safety to get patients taken care of. Even things that make sense, like scanning barcodes to reduce medication errors clog the system to the point where people resort to ad hoc measures to get the job done, even at the cost of reduced margins of safety. Part of the problem is competing priorities, though, not malevolence or incompetence on the part of system managers.
            Consider CMS’ primary care initiatives. There are data showing patients with access to regular primary care cost less, since they don’t go to the ER for minor ailments and some major ailments can be stabilized, thereby avoiding hospitalization. So, CMS has “incentives” designed to shift payment from episodes of care to monthly care management. However, a recent article points out several reasons why the effort is not likely to result in more primary care.[2] They show a heat map exploring the relationship between practice visits, the number of Medicare patients and the direction of practice income. The only practices likely to make money with these incentives are those with large numbers of patients who make fewer than 2.5 visits/year. Those with large numbers of complex patients with frequent visits will lose money. The authors note four primary challenges to the initiative, the first of which is the need for the change to be budget neutral to CMS. Second, CMS is pushing the changes before most practices have the capacity to handle population management—either personnel or procedures—and figure out how to deliver care effectively with the new dynamic. Third, less than half of all practices will receive an incentive payment—the rest will just see a reduction in fee for service revenue. Lastly, CMS’ initiative is not linked to any changes in other payment systems. The net result is fewer practices will participate than forecast and many marginally stable practices may be driven into hospital ownership. While CMS may think these are easier to manage, hospital bureaucracies have not shown any special skill at rapid adaptation to changing incentives.
            One of the unspoken assumptions behind the primary care incentives is patients will make better, (cheaper?) choices if they just have better information. I have always been skeptical—I don’t find people make better choices about smoking, drinking, eating, or engaging in risky sexual behavior based on education or social class. A recent article highlights the limits of tacit educational assumptions.[3]
           
       “Maybe, just maybe, the secret to saving money in the U. S. health-care system is to give the patients more information. At least that is the hope in some corners of the health-policy world. Armed with more knowledge about nutrition, the thinking goes, Americans might choose broccoli over burritos.”
 
            She reports the results of a working paper which used the military healthcare system, where occupation is routinely recorded, looking at areas of both overuse and underuse. When they looked at C-section rates, pregnant physicians were only slightly less likely than others to have one, and both were nearly twice the “recommended” rate. When looking at unneeded lab tests or medication adherence, there was no difference between physician patients and the others.
 
       “These findings, if strengthened by further research, would put a damper on the idea the U. S. can resolve inefficiencies in its health-care system by simply giving patients more information. For example, the concept behind high-deductible health care plans—in which patients pay higher costs before insurance kicks in—is that patients will research the prices of different procedures and avoid unnecessary care. But in this study, even the best-informed patients didn’t always do that.”
 
            This observation is not quite fair, though, because there is no direct cost to the patient in the military care system, although changes underway to curtail dependent care and shift it to “the economy” may change this. Nonetheless, the observation that physicians behave normally when they are patients is no surprise to practicing clinicians. In fact, the only place where they seem to differ much is in care at the end of life, where physicians are more likely to say “no” than the general population. This study also suggests universal access won’t solve any of these problems, since that is a characteristic of military medicine.
            So here we have a couple of good examples where pressure is being applied to physicians and health care organizations to make “change” all in the name of making care better and saving money. Yet the net result is likely to be more band-aids and more workarounds. If this were a lab experiment, we might note the rats are very good at problem-solving, just not very good at behaving the way the experimenters predicted.
            Is there a path toward improvement? Maybe—let’s start with patients. Swenson recently reported how five leading organizations find out what patients want.[4] And it is not by anonymous survey. He described it as “three wishes.” First, “care about ME.” Second, “care about each other.” Third, “put my interests first.” Sounds simple enough, but it is not done often and the larger our organizations become, the harder it is to see individual patients. But these questions lend themselves to slogans, which might at least get it back to the center of the thinking in these organizations. Bill Clinton reportedly used the mantra “It’s the economy, stupid” to power his election as President. Maybe we should keep the mantra “It’s about the patient, stupid.” Then we might be able to stop doing so many work-arounds.
 
17 September 2019


[1] Brown T. The American Medical System is One Giant Workaround. The New York Times, 5 September 2019. Accessed same day at https://www.nytimes.com/2019/09/05/opinion/hospital-workaround-health-care.html.

[2] Seesums LL, Basu S., Landon BE. Primary Care First—Is It a Step Back? N Engl J Med 2019;381(5 Sep):898-901. doi: 10.1056/NEJMMp1906593.

[3] Khazan O. The Discouraging Way Doctors Are Just Like Their Patients. The Atlantic, 9 July 2019. Accessed 10 July 2019 at https://www.theatlantic.com/health/archive/2019/07/what-doctors-are-like-as-patients.html.

[4] Swenson S. What If Our Care Were Designed by Patients? Accessed 19 June 2019 at https://catalyst.nejm.org/videos/care-designed-by-patients-three-wishes/

Further Reading

Beyond Toxic Organizations
Are medical organizations toxic environments or is the problem one of changing generational expectations?

Conflicting Economic Models
Providers are being forced to take on financial risk for the cost of care as shown by recent news articles.

Organizing for Success - Lessons from Keystone
 The Keystone Cooperative ICU Project obtained major improvements in safety. The "soft science" lessons need to be applied more widely.

Putting Patients At The Center Of Healthcare
 Putting patients at the center is crucial for healthcare organizations, but how can it be done?

Risk, Reward, and Other Reasons Patients Don't Follow Medical Advice
 Patients often don't do what their doctors recommend.  The problem is important and contributes to "bad" outcomes, yet we have little insight into the problem.