Monday, January 8, 2007

clinical innovation, bottom-up mindsets, Twenty Clinical Innovations to Build Patient-Doctor Trust: Nineteenth in a Series

Health Care Mindsets and Health Care Buckets

I am slated to give the keynote address at a “comprehensive national summit meeting on quality/performance, management, and compliance in healthcare” in late January.

Most other speakers hail from the health care summit. They include government officials, compliance experts,Joint Commission surveyors, leaders of various health care organizations, business CEOs, consultants, and health care lawyers.

These bona fide experts look down from above. They oversee, regulate, enforce the rules, make sure federal mandates are met, manage the system, and otherwise strive to improve health care. On the other hand, I am speaking of innovations from the “bottom-up” – from the clinical trenches. Like other speakers, I too seek to improve the system, but from a different vantage point – through innovation to enhance the patient-doctor relationship.

At the meeting, I will introduce my coffee-pot theory of health care, as set forth in this title and subtitle for the talk.

Key Innovations for 2007

A Coffee-Pot Theory for the Health Care System
Boil it up from the Bottom,
Before Letting it Percolate down from the Top

One’s mindset about what is taking place depends on one’s point of view. If your mindset tells you health care needs to be seamlessly integrated for the common good under one national umbrella, you think a certain way. If your mindset says health care is running amuck, about to plunge over the economic cliff, taking the nation’s economy with it, you think another way. If you think health care is self-correcting, based on market-based feedback and smart health care consumers capable of judging and choosing quality care, your thinking framework differs.

Health Care as a Series of Buckets

I recently ran across this arresting statement by Clayton Christensen, a professor at Harvard Business School and author of such books at The Innovator’s Dilemma (1997) and The Innovator’s Solution (2003),

“The current health care system is divided into buckets. You have the insurers, the employers who put up the money, the providers such as doctors and nurses, and the hospitals. Because they exist as independent companies, they can each improve themselves, but they can’t re-architect the system in the way it needs to be changed.”

Christensen praises integrated systems, such as Intermountain Healthcare in Utah and Kaiser Permanente in California. He argues these systems work efficiently because they integrate buckets across the system. He says integrated systems are effective business models because they enforce “rule-based diagnosis and therapy.”

As an example of the power of “rules-based diagnosis and therapy,” he cites MinuteClinics, where this sign appears on clinic doors,”We treat these 16 rules-based disorders,” which include strep throat, pink eye, urinary tract infection, earaches, and sinus infections,” for $39 each with no waiting.

Christensen is persuasive. but I would point out three things:

1) Physicians delivering care at integrated systems like Intermountain and Kaiser currently comprise only about 10 – 12 % of America’s doctors;

2) MediClinics and other retail outlets aren’t usually part of integrated systems;

3) Patients fall into “buckets” too.

Patient Buckets

Patient “buckets” includes:

1)Patients seeking beauty enhancements – facelifts, tummy tucks, breast augmentation or reduction, nearsightedness correction by Lasers, hair transplants, cosmetic surgery, liposuction, varicose veins erasure, and Botox injections. For the most part, health plans do not pay for these treatments. The treatments have become subject to market forces and have shown dropping prices because of competitive forces..

2)Weekend warriors, mostly aging baby boomers, seeking lifestyle improvements - knee and hip replacements – so they can return to full-function. Health plans pay for these procedures, the costs of which remain high because they are performed mostly in separate hospitals’ and specialists’ buckets.

3)Patients suffering from life-style abuses - coronary artery disease, lung cancer, chronic obstructive lung disease, other smoking related diseases, obesity connected diseases (heart disease, congestive heart failure, diabetes, hypertension, dyslipidemias, and metabolic syndromes), cirrhosis, and esophageal varices. Insurers pay for treating these problems, as they should, but many patients may have a hard time getting insurance because of “pre-existing disease.”

4)Non-compliant patients – who do not follow doctor’s orders, do not fill their prescriptions, do not lose weight, do not exercise, and who resist doing what is good for them. Again insurers pay. In a capitalistic democracy, after all, individual freedom to do what one wants comes with the system. Part of the problem here may be that doctors do not clearly or effectively educate patients to the consequences of their noncompliance. Part of the problem is lack of money. Part of the problem is, well, people will be people.

5)Gravely ill patients with degenerative or fatal diseases of genetic, environmental, or unknown cause – childhood malignancies, cystic fibrosis, autism, most cancers, rheumatoid arthritis, rare diseases, or diseases of the nervous system (multiple sclerosis, Parkinsonism, amyotrophic sclerosis, Alzheimer’s). As a compassionate society, we are obligated to take care of these folks, no matter what the cost, no matter what bucket is involved..

6)Inevitable diseases of old age as our biological clocks tick down, and we end our life spans before five score years, no matter what we do or how we live. Death from old age is an inevitable outcome for us all. None of us are going to get out of this alive. We all fall into the same bucket.

Self-Evident Truths and Countervailing Realities

In my talk, I outlined these “self-evident truths,” many of which may smack of political incorrectness because they show some diseases are beyond the physician’s control, whether these diseases are “rules-based” or not. Although it is heresy to say so, many diseases are culturally-based and have little to do with the health system.

•People spend 99.9% of their time outside of doctors’ offices and hospitals, and many do what they want to do, no matter what the doctor says.

•Many patients do not follow doctors’ orders – 30% never fill prescriptions, 25% don’t get needed refills, and an estimated 90% avoid exercise.

•Many chronic diseases– heart ailments, COPD, cirrhosis, alcoholism, hypertension, diabetes, to name a prominent few-- are life-style related.

•Half-way technologies – stints, coronary bypasses, joint replacements, and statins –don’t eliminate underlying diseases or change their basic pathophysiology. In other words, physicians can’t save many patients once the disease horse is out of the barn.

•Many people dig their graves with their own teeth, hence, the obesity epidemic.

•The cultural environment and society’s habits limit what can do: modern technologies. For example, the love of cars, lack of sidewalks and footpaths, and the explosive growth of computers, video-games, TVs, and home computers – foster obesity.

•Gaps between expectations and results are inevitable and lead to disappointments, dashed expectations, and law suits.

Then I set forth two “countervailing realities” that make a huge new health system “bucket” -- consumer-driven market-based health care – impossible to apply across the health care spectrum.

•One, consumers lack real-time, relevant, and understandable information to comply with provider instructions or to change behavior.

•Two, many non-preventable diseases – Parkinsonism, Alzheimer's, ALS, MS, and non-smoking related cancers, or more simply, the ravages of old age and multiple organ failure – are beyond consumer power to control.

These “self-evident truths” and “countervailing realities” make health care what it is. It is personal and emotional. It is heterogeneous humankind in action and in decline.

It is difficult to apply rules in all circumstances and to set up a bucket brigade that covers all eventualities and to put out every fire ignited by dysfunctional separate economic entities, human misbehavior, and illnesses that strike for no apparent reason, “Acts of God, ” as they are called.

But do not despair.It is never too late to innovate, whether at the summit or in the valleys, to improve access, convenience, affordability, and to work to prevent early death.

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