Starting With Curious

…is another one’s treasure, as the saying goes.  This is an important principle to bear in mind as the US tries to get a handle on healthcare spending.  As health economist Uwe Reinhardt notes in a recent New York Times blog, value is often in the eye of the beholder.

The 2012 Institute of Medicine report, “Best Care At Lower Cost,” examined the estimated $765 BILLION in “waste” (of the total $2.5 Trillion in annual spending on health care), and broke it into six categories:

1. Unnecessary services – $210 Billion
2. Excess administrative costs – $190 Billion
3. Inefficiently delivered care – $130 Billion
4. Excessively high prices – $105 Billion
5. Fraud – $75 Billion
6. Missed prevention opportunities – $55 Billion

This table leads to some finger pointing.  Physicians can blame pharma, insurers can blame docs, and everyone can blame those who commit fraud.  It’s tempting to think we can make significant progress without having to do much ourselves.  Take administrative costs.  (Please.)  We’re all familiar with the statistics – a recent estimate, for instance, that the typical US physician spends nearly $83,000 in her or his time dealing with administrative issues, four times as much as their Canadian counterpart).  And we have our own frustrating experiences: when I started as a faculty member at AI DuPont Hospital in Wilmington, DE – with a catchment area that included parts of four states – I had to complete a 7 inch thick stack of insurance enrollment forms for the over 60 different payers we had contracts with.  Our own clinical practice services at MCW – the folks who do the billing and collections for our professional fees – employ around 500 people, or nearly 1 for every 3 providers!  Why focus on “unnecessary services” when we could shave nearly as much by eliminating the non-value added “administration.”

But every one of these categories, seen as waste from the system perspective, benefits someone.  Even fraud.  So any effort to decrease these will face some resistance, on top of any other barriers.  Decreasing administrative costs by, say, having a universal credentialing process and single claims platform, would costs tens if not hundreds of thousands of jobs.  And decreasing “unnecessary” utilization means less revenue to providers, meaning less resources to take care of the needy and advance knowledge.

It  does seem like a zero sum game.  But there’s one perspective we haven’t yet considered – the patient’s.  If we streamline the insurer bureaucracy, it might mean some of those people paid to deny claims may not be needed, but the hospital gets paid faster.  But more important, patients are more likely to get the care they need. If a $100 brand-name albuterol inhaler can be replaced with a $15 generic, it hurts the manufacturer, but it helps the patient who can perhaps afford to buy both that AND a controller med to keep from getting ill in the first place.  And yes, if I order fewer CT scans in children at sufficiently low risk after head injury that it’s almost certain to be negative, my bottom line suffers.  But the child is less likely to have a radiation-induced malignancy later in life.

One person’s trash is another person’s treasure.  But to the person who should be at the center of all of this – the patient – it’s all trash.

I am rarely mistaken for George Clooney, and my job seldom resembles the TV show “ER.”  The vast majority of what we do is, at least after a number of years, pretty routine.  But every once in a while, life resembles art.  A couple of months ago, on an otherwise steady but undramatic day, the nurse walked a 2 week old baby back from triage and asked for immediate help.  The baby was blue, not breathing, and had no pulse.  A team of folks – nurses, other doctors – swiftly descended on the room and began working.  I directed one person to do CPR, others to try to get an IV and to give medications.  After a minute or so we were able to get a pulse, but the initial signs weren’t great.  The parents, who were in the room with us, asked if they should baptize the little girl, and they did.  After almost an hour, we had stabilized her and sent her to the neonatal ICU.  I went up and checked on her and her parents after my shift.  While things were improved, it was all still quite tenuous.

This past weekend, the triage nurse came back and told me and one of the nurses that there was a family in the waiting room that wanted to talk with us.  We went out to find the family of that little girl.  They wanted to thank us for what we had done, bringing a delicious lunch for the whole staff.  It was a touching gesture, as were the drawings from the girls siblings that said “Thank you for saving our sister’s life.”  But the best thing was seeing the baby herself.  She had spent a month in the ICU, but did well and went home.  The last time we had seen her she was literally on death’s door; now she was a pink, chubby-cheeked, smiling 3 month old.  As we exchanged thanks and hugs, all of us were a bit teary.

I happened to have a college senior interested in medical school shadowing me that day.  As we were sitting down to enjoy the pizza and ravioli, I told him that this sort of thing doesn’t happen every day, or even every year.  But, I said “This is what it’s all about.  Don’t forget that.”  It’s all about purpose – acting in the service of children and their families.

I also thought of our emphasis on “being here now.”  When the team swung into action that day a few months earlier, each of us was there, fully present, doing what we needed to do.  We were also there for the family, explaining what we were doing and what it meant even as we feverishly worked to save their baby.  And when that family returned, intact, to bring us a meal, it reminded me that it could have been very different.  Life is short, unpredictable, and very precious.

In our efforts to promote value, the need to reduce unnecessary variation and follow best practices in the form of clinical guidelines is clear.  As we think about moving toward more evidence-based practice, it may be worth considering some of the alternatives:

1.  Eminence-based practice.  This is where we do what we are told by people who, rightly or wrongly, are well-known in their field.  Although in many cases this may be reasonable and congruent with available evidence, assuming something is correct based solely on the celebrity of a source can be problematic. (See, for example, Tom Cruise and Scientology.)

2.   Precedence-based practice.  This falls under the category of “we’ve always done it that way.”  It is particularly prevalent at certain ivy-clad East Coast institutions, and is the reason we continued to use theophylline for acute asthma well into my fellowship years.  (The cutting edge doesn’t work when it is stuck in cement.)

3.  Elegance-based practice.  This is perpetuated by pharmaceutical and other manufacturers, who promote questionable products with eloquent testimonials and attractive advertising.  The poster child for this is Xopenex.

4.  Arrogance-based practice.  When one is willing to substitute one’s own thin anecdotal experience for the accumulated wisdom of the published literature.  Often expressed in the form of “my patients are different.”

5.  “Are you dense?”-based practice.  Also known as “execrance-based practice,”  this is an extreme form of variant #4 above, whereby not only does one assume one’s own practice is superior to the published evidence, but that all other practices are idiotic.

One of my favorite questions to ask fellowship applicants is what skills they think are important to be a good pediatric emergency physician.  Almost all of them respond with something along the lines of being able to multitask, building and leading a team, and maybe procedural skills.  When I point out the importance of those skills for almost any specialty, and ask for those skills somewhat unique to our field, many draw a blank.  To my mind, one of the unique skills of an emergency physician – indeed, one of the defining features of the specialty – is the ability to make decisions with incomplete information.

Of course, no one ever has truly complete information, but the limitations due to time and resource constraints in the setting of the ED are much greater.  Physicians have to determine and commit to a plan of action despite the fact that the patient’s history may be limited by the absence of a caregiver, or a prior relationship with the patient and family; some tests may not be available in off hours, and results of tests that are performed may not be available until after the decision has to be made; and competing demands more significantly limit the amount of time we can spend with a patient than in a scheduled setting.

Comfort with making decisions in the face of incomplete information, and being able to do so with an appropriate level of confidence, is a critical skill for the emergency provider, but is useful in a variety of contexts.  For example, business leaders must often make strategic decisions vis a vis their competitors without good intelligence on what the competitors’ plans are.  In a rapidly evolving healthcare environment, hospital and other leaders face a number of key decisions that will have impacts for years, when we don’t have a good deal of information about what the environment will look like even months from now.

This skill requires some humility: the less information you have when you make a decision, the more likely it is to turn out to be a bad one.  It also requires a thick skin, as the next-morning quarterbacks are all too happy to wonder aloud about what those people in the ED were thinking.  I have long contended that, although some people may never be comfortable with making decisions in the face of incomplete information, most of us are capable of doing so, and that it is a skill that can be developed through practice.  Recently, I read a fascinating book about decision making by the Nobel Prize-winning economist Daniel Kahneman that provides some support to this.  Thinking, Fast and Slow – about which I will comment more on in future posts – describes the two systems in our mind that are involved in decision making.  System 1 (in Kahneman’s terminology) is the one that allows us to form immediate impressions, take automated actions.  It is responsible for snap judgments.  As such it performs an important function (our forebears would have had a hard time if they had to do a thorough risk analysis every time they were chased by a large carnivore) and usually does pretty well, though it is subject to a variety of biases.  System 2 involved the slower, more conscious and overtly analytical processes that provide a check and oversight over System 1.  One could surmise that making decisions without complete information might involve suppressing System 2, allowing us to go with our gut impressions.  But in fact, it turns out that, again in Kahneman’s words, system 2 is “lazy”.  The challenge is not to suppress it, but to invoke it.  I suspect most of us realize that our gut impressions are subject to bias.  It’s why we have sayings like “don’t judge a book by its cover,” and why we abhor racial profiling.  As a result, I believe that we are suspicious of our System 1 judgments, and overcompensate by insisting on a thorough System 2 review before committing to anything.  Being able to rapidly do a System 2 check of System 1’s snap judgment, and recognizing the strengths and limitations of both, is key to successful decision making with incomplete information.

It can be a challenge to efficiently bring our System 2 to bear on decisions that seem time sensitive, especially when there are many such decisions to be made in a brief period.  Interruptions and distractions, things that keep us from focusing attention, will tend to degrade the quality of decisions.  The ED is rife with those distractions.  It requires a certain amount of mindfulness, of “being here now,” to use our System 2 most effectively.  It is that mindfulness that we can exercise as a way to make better decisions when we do not yet have all the facts.

Getting ready to leave the Medical College of Wisconsin and move to Children’s Hospital of Wisconsin has made me a bit nostalgic.  I recalled recently when I was interviewing for my first job after fellowship, I was asked by my soon-to-be boss how I would design the ideal academic position.  I described what was the predominant model at academic children’s hospitals for my specialty of emergency medicine: approximately 60% clinical time, with the rest devoted to scholarly activity (education and research).  To my chagrin, he replied that model was becoming extinct.  People would have to choose to be 80-90% clinical or 80-90% academic (and get the external funding to support that).  I ended up in the 80% academic track.

Here it is 20 years later, and in many places, including ours, that is still the model.  But Brian Strom was correct.  The death of that model occurred earlier in Philadelphia and some other places than here, and perhaps in adult medicine ahead of pediatrics, but the trends are clear.  For a long time we have heard that the “triple threat” (i.e., the superhero physician who is clinician, educator, and researcher all rolled into one) was no longer possible because only those with a singular focus on research could compete successfully for extramural funding.  But many academic physicians do research that is internally funded with excess clinical revenue. The idea that the margin generated by spending 60% of one’s time in clinical work can support the other 40% is simply no longer tenable.

This was underscored by a set of articles about the future of academic health centers that appeared recently in JAMA and NEJM.  The articles talk about a variety of challenges and potential responses.  But a common theme is the unsustainability of cross-subsidization of the academic missions by the margin generated by clinical activity.  That margin is being eroded by downward pressure on reimbursements, at the same time alternative sources of funding for research and education are drying up.  The relative size of the clinical and academic activities is going to have to change.

For children’s hospitals, especially, where the paradigm of the triple threat has tended to hang on, we will have to rethink what it means to be an academic physician.  Rather than every faculty member participating in all activities, we will need to specialize.  The majority of faculty will be excellent clinicians who may do some bedside teaching, and provide access to patient material for clinical and translational researchers, but who will not themselves be expected to generate traditional “scholarly products” such as peer-reviewed articles, abstracts, book chapters, etc.  Their efforts, however, will generate sufficient margin to allow a smaller cadre of colleagues to engage in research and core educational activities.

This would represent a significant cultural change for us, leading to some serious soul-searching.  How do we continue to provide adequate intellectual stimulation to people who are “only” clinicians?  Would the pay scale be similar for clinicians and academics?   How do we ensure that prestige and career advancement are equally available to those doing the clinical work, when the traditional path to promotion and success has been via grant funding and publication?  What is it exactly that makes someplace an “academic health center?”

Fortunately, we are not the first to face these questions.  An article about the experience of Brigham and Women’s Hospital, for example, provides some encouragement.  But I wonder if someone who trained at the Brigham 20 years ago would recognize the place anymore.  Nostalgia may be fun, but we can’t reminisce our way forward.

When people find out what I do for a living, the first response is most often something along the lines of “That must be so hard.”  (That’s when they find out I’m a pediatric emergency physician; when they hear I’m also an administrator, it’s more of a sneer.)  My reply is typically that most kids are pretty healthy, and most of what I see is fortunately not that serious or ends well.  Which is true.  But the fact is, sometimes it is hard.  All of us in medicine have ways of coping with those difficult times, with patients who suffer and whom we can’t help as much as we’d hope to, with the child that dies.  But, as discussed in a recent New York Times article, too often that coping mechanism is to distance ourselves.  This detachment – which can cross over into callousness or cynicism, as documented famously in Samuel Shem’s novel The House of God – is contrary to the various oaths we take when entering the medical profession, in which we pledge to be compassionate and empathetic to the sufferings of those we care for.  It can play out in several ways.  Some physicians focus on the intellectual aspects and science of medicine.  For others, emotional detachment along with time and economic pressures can lead to burnout.

For all of us, underemphasizing the humanism and altruism, combined with the increasing emphasis on medicine as a business, can lead us to feel like we are in an occupation, rather than a profession – a calling.  We can forget what it is about medicine that gives it real meaning.  Work hour restrictions, preauthorizations, shared savings and pay-for-performance:  these are some of the reasons why many long-practicing physicians say medicine has changed for the worse, and they wouldn’t recommend it to their children.

Perhaps we need to be reminded of the old-fashioned commitment to the well-being of a patient, to being a healer, as a counterweight to economic and administrative pressures to be efficient.  Lest we get too nostalgic, however, let me put in a plug for the administrators.  As noble as the sentiments expressed in the Oaths of Hippocrates and Maimonides are, the singular focus on the individual patient can blind to the equally real needs of others, and more importantly, the fact that those needs must be balanced.  There is only so much health care to go around.  While we like to think that when we are sick, we want everything done and money is no object, that sentiment is typically expressed when we are not paying for it.  The decrease in health care utilization that accompanied the economic downturn of 2008 and beyond shows that money is, in fact, an object, at least for many people.  And with a few extraordinary exceptions, not many of us providers are willing to work without pay (and quite decent pay at that).  In a world of limited resources, we need to balance our commitment to healing the person in front of us with the commitment to the health of society as a whole.

Those who provide the care and those who manage it need to understand each other better. We need to recognize the filters through which we see the world, accepting that a diversity of views is the best way to see the big picture.  I believe as a provider, I may need to err on the side of connecting with and advocating for my individual patient.  The administrator may need to be more vigilant about the efficient use of resources.  But we must appreciate that we are all working toward a common purpose – serving our patients and their families – and a common vision of having the healthiest kids in the country here in our own community.  Each of us can find meaning in what we do, and have an impact in our own way.

It shouldn’t be surprising, in a time of shrinking payments to providers, that turf battles among those providers are increasingly common.  But we need to make sure that we don’t just hurt ourselves in the rumble.  Or worse, forget about what is best for our patients.

Round 1 in the gang war seems to be between physicians and advanced practice providers.  Many see APPs as an important part of addressing both the excessive cost of healthcare and the access issues that arise from an inadequate supply (or maldistribution) of physicians.  On the one side are the APPs, who are advocating for changes in state regulations that place limitations on their scope of practice.  Currently, 17 states and DC allow independent NP practice, 21 (including Wisconsin) require a collaborative agreement with a physician, and the rest require direct physician supervision.  Although the evidence is mixed on whether expanded scope of practice contributes to lower cost or better access, there is no evidence that it leads to worse outcomes.

Yet lined up on the other side is organized medicine.  The AMA, American Academy of Pediatrics, and American Academy of Family Practice have all issued reports decrying expansion of scope of practice for NPs.  (The politics indeed makes for strange bedfellows.  For example, both the AAFP and AAP emphasize the additional years of training for physicians compared with NPs.  Yet the total pediatric training for family physicians is far less than that for pediatricians, and is likely very comparable to the duration of pediatric training for a pediatric NP.  And certainly, a PNP with several years of experience after training has seen a whole lot more pediatrics than a new FP residency grad.)  In addition to lobbying state legislatures to maintain practice restrictions, the medical associations pressure insurers to limit payments for NP services.  Even when permitted by state law to practice to the full extent of their license and training, NPs are frequently not credentialed by insurers to bill directly.  In response, nurses are lobbying for a requirement that NPs be included in any plans offered in the new health insurance exchanges.

There is a real discussion to be had about how we develop a workforce to meet the medical needs of children in the evolving healthcare environment.  But can we call a truce and focus on the real issues?  Let’s be honest: this is not primarily about patient safety, or quality of care – it’s about preserving jobs and incomes.  One (not normally extreme) columnist went so far as to call the medical profession’s efforts to limit NPs “a protection racket.”  That’s harsh.  But it doesn’t serve us or our patients for health professionals to be rumbling with each other.  It seems clear that there is a legitimate role for advanced practice providers in meeting the primary and specialty care needs of children, and that role includes independent or collaborative practice in many cases.   That doesn’t mean NPs and MDs are interchangeable.  But the two disciplines need to acknowledge the filters through which they see the world and come to agreement on how we can ensure the right provider for the right patient in the right circumstance.  Or our patients may get caught in the crossfire.

When even a child of the 60s and 70s like me is connected via texting, Twitter, Facebook, etc., it’s safe to say that the digital revolution is over, and digital won.  The last holdout, it seems – the analog equivalent of the tsarist White Army – is health care.  Sure, we have robots for surgery, telemedicine for remote diagnosis, and an increasing use of electronic health records by hospitals and providers, but it still feels very old school.  Sort of like education: even if you take notes on an iPad, attending a lecture is still a very traditional method of learning.  Health care is still very provider- and facility-centric.  To paraphrase the NY Times columnist Thomas Friedman, the world of health care has still not gotten very flat.  Yet there are some steps toward leveraging new modes of communication that have the potential to disrupt the model of health care delivery.

Many people today use texting as their primary means of communication, but it is seldom used in medicine.  Expanding its use would not only be more patient-centered, but may really improve efficiency.  We recently ran a trial of texting appointment reminders to patients in our sickle cell clinic, which has a traditionally high no-show rate.  The day after text reminders were sent, only 1 of 14 patients did not come for their appointment.  Anyone who has ever dealt with a teen knows that this is a group where texting may provide a particular opportunity to vastly improve provider-patient communication.  Providers and staff appear to be open to the idea of greater electronic communication, but some barriers are apparent.  One is reimbursement: under current payment systems, electronic communication is a service for which it is difficult to collect a fee.  Another concern is confidentiality, though some progress has been made to ensure that texts or other electronic messages are secure, such as a HIPAA-compliant messaging app.

Texting of course, while seemingly radical by the conservative standards of health care, is not exactly a disruptive technology.  But some providers are pushing the envelope with “virtual clinics,” where almost all interaction is electronic.  Check out, for example, these examples in New York and Minnesota.  Experience is limited, especially regarding outcomes, but these experiments suggest that at least two elements of the triple aim – lower cost and better experience – can be met.

Medicine is clearly moving toward being a true team sport.  Many of the proposed innovations in care delivery and payment depend on a collaborative approach, with individuals from multiple health professions playing a role.  Perhaps the clearest example is the patient-centered medical home.  Which all sounds great, until you start to ask different people what they mean by a “team.”  Many physicians have a, well, physician-centric concept of a team, where the doctor serves as “quarterback” or “captain.”  And while teams generally need leadership, you can imagine that a nurse, social worker, or pharmacist might have a less enthusiastic embrace of a team where she or he can, by definition, never be the leader.  It’s not that physicians are trying to be uncollaborative.  However, medicine has traditionally been structured hierarchically (e.g., doctors write “orders,” not “requests”).   And this is reinforced throughout the training not only of doctors, but other health professionals as well.

To move toward a truly comprehensive, collaborative team approach, this approach needs to be embedded into the education of all potential team members, right from the beginning.  By the time medical and nursing students have completed their four years of school, patterns of thought and behavior – cultural constructs – are already developed.  This is why there has been an increased interest in interprofessional education, defined by the WHO as occurring when “students from two or more professional learn about, from, and with each other to enable effective collaboration and improve health outcomes.”   MCW’s Community Medical Education Program is exploring the possibility of incorporating interprofessional education into the curricula at the regional campuses, in conjunction with the other health professional schools in those communities.

Dr. Melanie Dreher, Dean of the Rush University School of Nursing, recently gave a presentation sponsored by the CMEP on interprofessional education.  She noted some of the dominant cultural constructs about medicine as a hierarchy that need to be revised, and the potential for interprofessional education to do so.  I’ll call out two.  The first is what I mentioned above, the idea of a team revolving around a single leader (typically a physician).  She offered the counterexample of situational leadership, where leadership of the team is flexible depending on the issue being addressed.  For example, if the issue is one of polypharmacy, then a pharmacist might assume the role of leader; if it is one of support services, perhaps the social worker.  An analog is the Orpheus Chamber Orchestra, a group in which the role of conductor is shared and rotated among all members, depending on the piece to be performed.  As they see it, it is not the conductor who is the center, nor even the musicians – it is the audience.  The other cultural construct is that of how we measure contributions to the team.  It can’t be by RVUs generated, or papers published, or referrals received, which ignores equally important roles played by many of the members.  Dr. Dreher offered the basketball example of Shane Battier of the Miami Heat, whom Michael Lewis referred to as the “no stat All-Star.”  He is considered one of the best defensive players in the league. But he has few points, rebounds, or assists –the conventional measures of success – and is therefore undervalued compared with high scorers, although statistics suggest that there is a stronger correlation between Battier’s playing time and the team’s record.

A true team approach means we need to fully utilize and recognize the unique knowledge, talents, and approaches provided by every member of that team.  Engendering that attitude, and teaching the actual skills of teamwork (which are separate from the skills inherent in being a doctor, nurse, or pharmacist) means we need to break down the silos in which health professionals learn.  It’s not a terribly new concept: when I was in medical school, the physician assistant students and medical students took several of their preclinical classes, such as anatomy, together.  It fostered a sense of collegiality and mutual understanding.  But is has not become widespread.  As we evolve toward a more collaborative model of health care, the way we educate health professionals must adapt as well.

I introduced this analogy at a Pediatric Grand Rounds on Population Health Management and Payment Innovation, as a way to conceptualize the changing role for providers in the evolving health care environment.  My grandfather was a cab driver in New York City in the 1940s and 50s.  He and most other drivers at the time were owner-operators.  Although there were some regulations around fares, etc., he was more or less on his own – he paid for his gas, insurance, upkeep, etc., and whatever he had left after paying expenses he kept.  What regulation there was, was enforced by the requirement for a medallion (of which there were a limited supply) in order to operate legally.  Within the constraints of government regulations, though, they set their own practice.  They could pick the neighborhoods they operated in, the hours they worked, the routes they drove.

How is this relevant to healthcare?  The medallion was the equivalent of a medical license (of which there are also, in practice, a limited supply), and he was in essence a solo practitioner.  Sometimes cabs would come together into a cooperative of several owner-operators, sort of like a group practice, but still controlled by the drivers themselves.

As the costs of obtaining a medallion and operating the cab (e.g., fuel prices) go up, it gets harder for an individual driver to make a living as an owner-operator.  Moreover, the system itself is inefficient and wasteful.  Lots of drivers want to be in the nicer neighborhoods where the tips are better; fewer want to drive long routes out of town with no way to recoup the time for the return trip.  Cabs circle around waiting for people who need a ride, wasting gas.  There is no way to efficiently match the size of the vehicle with the number of people in a party: a group of 6 might have to wait some time for a large enough car to come by.  So a system of leased cabs, managed by a cab company, evolved.  The company had a phone line, so people in need of a ride can call.  A dispatcher sends the closest, most appropriate size vehicle.  When the rider pays her fare, it actually goes to the cab company, not to the driver.  The driver gets a fee (he’s essentially an employee), the company pays the expenses (including not only the vehicle operating costs but also the salaries for the dispatchers), and keeps whatever is left as profit.  The company, not the individual driver, sets the guidelines about where and when the cab goes.  And a company that does a good job of minimizing costs benefits financially.  They will do that by paying as little as possible for a unit of service (cheaper insurance, less expensive gas, decreasing payments to the drivers), and by eliminating waste (e.g., not having drivers circling around, sending the right cab to the right place at the right time).

This is where the health care system is heading.  We are moving away from managing the medical care of an individual to managing the health of a population.  As specialists, we have been like the owner-operator cab drivers of my grandfather’s era.  We are used to focusing on providing a service to an individual patient and getting paid for that service, according to our own preferences and individual guidelines.  In the future, providers (and I use that term to include not only physicians but also hospitals) will be like the drivers in a cab company.  Payment will not go directly to the provider, it will go to the health manager (e.g., an ACO).  Like the cab company, this manager will use “dispatchers” to direct the right care to the right place at the right time.  Payment to providers will not be the usual fee-for-service: it may be a salary, or some modified payment for services but with shared risk or shared savings.  And of course, the health manager will attempt to minimize costs by pressuring payments to providers and eliminating unnecessary utilization.

Sounds bleak?  What provider in her right mind wants to be a cab driver working for a large company, being told what to do by a dispatcher?!  The hope lies in shifting our thinking from being an individual provider to being part of a system.  I, myself, might just drive the cab, but I have to be a fully-participating member of the company, with a voice and a stake in figuring out the dispatching protocols, minimizing variation and waste, and sharing in the profit (and risk) of doing a good (or bad) job.  In an era when health spending needs to come down from unsustainable levels, those who are only providers can only lose, in the form of lower reimbursement for fewer services.  But those who also participate in the function of managing the fleet can reap the benefits and thrive.  That doesn’t mean that someone who is now an allergist or a surgeon will stop doing what he or she does.  A cab company doesn’t survive without the cabs and great drivers.  It does mean that we need to figure out how to operate in the larger system, how to work with the managers and payers and primary care providers (and most of all, the riders) to reduce costs, provide a better service, and improve health.

One more note.  As first noted in a 1960 article by Theodore Levitt in the Harvard Business Review, railroads largely went bankrupt because they saw themselves as being in the railroad business, rather than in the transportation business.  As cars and buses flourished, demand for rail services went down.  We not only have to make the shift from being cab drivers to being a cab company, we need to be a transportation company.  Or, in our terms, we need to shift from being providers to being managers, and not just medical managers but healthcare (or better, health) managers.  When alternatives to hospitals spread, we’ll be better poised to bring our expertise to whatever those alternatives are.

“Don’t it always seem to go

You don’t know what you’ve got ‘til it’s gone…”