Starting With Curious

The tone of the debate over healthcare reform in Congress was predictably partisan.  But the tone of the public discourse over healthcare costs is taking a different, more visceral, and frankly darker tone.  If you haven’t yet read the recent cover story called “Bitter Pill Why Medical Bills Are Killing Us,”, I urge you to do so.  (If, like me, you get most of your news from The Daily Show with Jon Stewart, you can watch the interview with the author, Steven Brill.)  It’s not so much because of its original insights (you probably already realized a lot of what is reported), or because it is so factually accurate (a little more on that below).  But the article is a stark reflection of how the majority of Americans view the absence of value in our healthcare system.

The 38-page article documents the stories of six people’s medical bills, the associated sticker shock, and the apparent arbitrariness and irrationality of charges and payments for medical supplies and services.  As I read the article I found myself getting a bit defensive.  Don’t people understand about the need to subsidize care for uninsured or underinsured patients?  How can they complain about salaries in the healthcare field – have they seen what people on Wall Street get paid?  And, as documented by others (e.g., Joanne Conroy in the Huffington Post), some of the facts are a bit distorted.

But in broad strokes, this article makes a case that many others have made before – healthcare in this country is very expensive, and while some of it is because we utilize a lot of it, much of the reason is that hospitals and medications and tests and yes, physicians, cost a lot.  A recent blog in the Washington Post called health care prices “ludicrous.”  And as healthcare consumes an increasing and unsustainable portion of our economy, and individuals find they can’t afford the care they need, there is going to be a backlash.  We can rationalize and explain, but more and more people are just fed up.  This is why we all need to read and pay attention to this article; what I sensed was anger, more than anything else.  I’ve heard that anger in some of our families who complain about their bills.  I’ve heard it in conversations at parties.  I’ve heard it from business leaders talking about their healthcare costs.  I’ve heard it among commentators both serious and comic (Jon Stewart was in rare form about this).  To those who wonder if all the talk about change in the healthcare system is overwrought, and think it will all blow over in a few years like HMOs did in the 1990s, I would say this feels very different.  If we want to play a meaningful role or even drive the reforms, we need to acknowledge the passion, the frustration, the rage, before it is turned on us.

“Value” has become the new buzzword in healthcare, and for good reason.  But for a long time, those of us in the caring professions have emphasized our values, which really define us as professionals.

Children’s Hospital of Wisconsin has elaborated a set of core values.  Arising from our culture enhancement work, this represents a simple statement of who we are, why we do what we do, and how we act in our work.  It’s been really gratifying to see how our attention to our culture and our values is improving our ability to carry out our missions and to advance the health of children.

Our first value is Purpose: “We act in service of children and families.” This is about our passion and commitment to our missions – providing the best and safest care, advancing and disseminating knowledge, and advocating for those we serve.  Anyone who spends more than 5 minutes with our physicians and other providers can see that strong sense of purpose.  I see it in the physicians who put in endless hours making our EHR work, in the APPs who stay way beyond the end of their day (or evening) to avoid having to hand off the care of a child to another provider, in the speakers at our Best Practices conference who spent their weekend passionately sharing their expertise with over 370 community providers.

It’s also about recognizing that our patients and families are at the center of all of our activities, and our accountability to them for providing care that is effective, safe, efficient, timely, and equitable.   Finally, it is about our accountability to each other and to the organization, including our responsibility for being stewards of our resources so that we and those who follow us will be able to serve our patients, families, and community for a long time to come.

Having had the privilege of working in several other children’s hospitals, I think our commitment and passion really distinguish us – this is one of the most purpose-driven organizations I’ve ever seen.  And there is real value in that.

That was the old Midwest Airlines motto.  I’ve been traveling a bit lately, which often makes me reflect on the parallels that have been drawn between the aviation industry and health care, and the notion that we in medicine can learn from what has been done to maximize safety in commercial flying.

This time, I was also pondering what we might learn from the service and efficiency aspects of aviation and the hospitality industry.  Yes, airlines hardly have a reputation for customer service, but then again, neither does health care.  Consider the following:

– Self-service check in.  I’ve seen airport-style kiosks used successfully for families to register at another children’s hospital with a very busy orthopedic clinic.  Families were highly satisfied, the process was timely, and fewer registration personnel were needed.  How could we make the check in process more efficient and user friendly?

-Text reminders.  On my last flight, I got text reminders of flight status and gate locations.  Could we use text messaging or other means to remind families of appointments, notify of delays, prompt for feedback, etc.?  We also need to think about using available technology to communicate more broadly with families – e.g., test results, questions, etc.  MyChart will be a step in this direction, but how can we make it as accessible as possible?

– Scheduling.  Twenty years ago the only way to book a flight was through a travel agent.  Airline scheduling was supposedly so complicated only a professional could do it.  When was the last time you spoke with a human to book a flight?  True, clinic scheduling algorithms can get complicated, but the vast majority could be computerized and automated to allow families to make appointments at their convenience.

-Customer loyalty programs.  We often (and sometimes pejoratively) refer to patients who have a lot of contact with us as “frequent flyers”.  Frequent flyers on airlines get certain perks.  What could we do to encourage or reward our frequent flyers?  The same is true of those who refer patients to us.  A complaint I’ve heard from our CMG physicians is that they get no tangible benefit from being part of our system in terms of facilitating patient referrals.  Perhaps we can explore expedited access or other incentives for our most loyal customers?

-Training.  People who work in service industries have to be skilled at what they do – pilots need to be highly competent at flying, maintenance workers have to know how to keep the machinery operating, chefs better be able to create delicious meals.  But they also receive specific training on how to provide excellent service. I’m not suggesting we sacrifice the effectiveness domain of quality for family-centeredness.  But the best care does both. What do we do to make sure that everyone who has contact with patients and families is not only skilled at her or his job, but can also make the experience a satisfying one?

Being able to provide not only the most effective and safest care, but also care that is efficient, timely, and patient- and family-centered is important for several reasons.  First, for a lot of our services, families have other options for providers that, if we are honest, we can’t always differentiate ourselves from on the basis of effectiveness or safety.  We will need to compete on other aspects – cost and service – to attract them here.  Second, even in those instances where we provide care that is clearly more effective, poor service can create enough of a barrier that families may seek care elsewhere.  Finally, if quality care is defined as the kind of care you’d want for yourself if you needed it, think about the times you’ve been a patient or parent of one.  Let’s face it – service matters!

OK, time for me to go through security.  At least we don’t have the TSA in our lobby.

In an earlier posting, I discussed evidence regarding how physicians respond to financial and other incentives such as pay for performance.  Many experts propose that increasing financial incentives for patients is an effective way to control health care costs.  The rationale is that spending is driven in large part by artificial demand from physicians who are paid based on volume of services, on the one hand, and from patients who, due to insurance, are insulated from the costs of the services they consume.  Can informed patients, armed with information about quality and cost, and having to pay those costs directly, drive the triple aim of higher quality care, lower cost, and better health outcomes?

It turns out there is some evidence on this topic.  In a classic study, and one of the few randomized trials of payment innovation, the RAND Health Insurance Experiment showed that when patients and families bear a larger share of the costs directly, via co-pays and other forms of cost sharing, they cut back on their utilization of medical services.  However, they reduce both necessary and unnecessary services similarly.  This suggests that having patients have more “skin in the game” can lower costs, but may actually lead to worse outcomes (although the study did not actually find worse health outcomes despite the decreased use of services).  Other studies, largely observational, have mixed but generally similar findings.  It’s not clear why this is.  It may be, as many health professionals argue, that medical care is too complex for even reasonably informed but untrained people to make judgments about quality.  Another possibility is that, given how expensive medical care has become, for most people with average means, there is no choice but to make decisions based almost exclusively on cost.  A co-pay of $175 for an emergency department visit may serve as an effective deterrent to seeking care even when needed if that represents a day’s pay (which it does if you make the median income for a family of four).

The challenge of looking to consumers to drive the push to lower health care spending is underscored by a recent study in Health Affairs.  Researchers at RAND conducted a set of focus groups among individuals with insurance to describe their willingness to discuss and consider costs when making health care decisions, and to identify barriers.  It may not come as a surprise to those of us who deal with patients and families, but there was in fact tremendous resistance to considering costs.  Participants expressed a preference for the “best care” regardless of cost, driven in part by equating “more expensive” with “higher quality.”  Moreover, there was a classic “tragedy of the commons” thinking, in that people felt that since they had paid into the common pool via insurance premiums, they were entitled to all they could get out of it, with no individual responsibility for stewardship of the shared resources.  As one participant said, “I probably should care, because we all pay in the end.  But in the heat of the moment, I’d be like ‘Fix my problem! I don’t care about anyone else.'”

As the saying goes “Everyone wants to go to heaven, but no one wants to die to get there.”

What do we as providers do?  I would argue that the evidence to date demonstrates that we will need to take a leading role.  To start with, we can eliminate waste in the form of unproven treatments, unnecessary testing, and duplication.  We can focus on the efficiency dimension of quality, along with the other dimensions such as effectiveness.  We can embrace rational, evidence-based guidelines to minimize unwarranted variation, such as the Choosing Wisely effort by numerous professional organizations.

I don’t want to minimize the challenges of doing so, highlighted by the recent findings from the Health Affairs study discussed above.  But anecdotally I have found that this approach can work.  One of the five interventions proposed by the American Academy of Pediatrics was to decrease the use of CT and increase the use of observation in children with minor head trauma, based on an evidence-based decision rule.  Since that rule was published, we have seen a decrease in CT scanning in our ED.  I find it far easier to talk with families with that rule in hand, explaining how the quantifiable risk of a bleed is outweighed not only by the economic cost but by the potential harms due to radiation exposure.  I’ve actually been surprised at how many people are receptive to discussing cost, as long as it’s framed in the context of their child’s health first.  If heath care spending is to come under control it will have to be led by us, health professionals who are able to balance our obligation to the individual patient in front of us with all the other potential patients out there.  Health care is a common good, and we need to be its stewards.