NEJM’s $640 Billion Question

By Alina Hsu

Why does cost-effective care diffuse so slowly?  Because of various kinds of resistance and countervailing forces across many stakeholders:  insurance companies, large employers, the public (largely influenced by inaccurate media reports), legislators, hospital administrators, physicians, academic health centers, and the manufacturers of drugs, medical devices and equipment.  The article is available as a free pdf, which I encourage you to read.

The authors, Victor R. Fuchs, Ph.D., and Arnold Milstein, M.D., M.P.H., are insightful in their analysis of these stakeholders and forces.  The road ahead is indeed daunting.  They end by calling on physicans to take the lead:

“The Physician Charter, a modern version of the Hippocratic Oath, has been adopted by physicians’ organizations that include a majority of U.S. physicians. It ethically commits physicians to working toward ‘the wise and cost-effective management of limited clinical resources.’ There is not much that physicians can do directly to change the behavior of insurance companies, employers, or other stakeholders, but physicians are the most influential element in health care. The public’s trust in them makes physicians the only plausible catalyst of policies to accelerate diffusion of cost-effective care. Are U.S. physicians sufficiently visionary, public-minded, and well led to respond to this national fiscal and ethical imperative? It’s a $640 billion question.”

The one perspective that the authors miss, and I think it is a critical one, is the systems perspective.  This is about the relationships and feedback loops that link, drive, and dampen the behavior of the individual stakeholders.  We have learned from decades of lean transformation efforts that one of the most powerful leverage points for changing a system is changing its goals (and measures, and making those measures transparently available).  A suitable goal here is, I think, IHI’s Triple Aim.  In addition to cost-effectiveness you need to include population health (the real value of health care) and patient experience (which itself includes such things as quality, equity, timeliness, respect, and engagement).

Further, you almost always cannot change one component and expect that to drive the transformation of the whole.  Several other reinforcing changes need to be made nearly simultaneously, in order for the initial transformation effort to survive and later expand.  Otherwise, the system is unstable for awhile and often settles back into something close to its original state.

The CDC’s health policy simulation, which I blogged about earlier, may provide some insight, but is more abstract than Fuchs’ and Milstein’s analysis.

So what other changes might be needed?  Vermont’s no-fault malpractice would relieve some of the pressures on physicians.  ACOs would also support the goals and the direction in which we want the system to move.  We may need patient advocates to help patients learn new ways to interact with physicians and other providers, or to represent them when they are not willing or able to engage.

Do you disagree?  If we assume that new goals + physician commitment are the key to a transformation, what else is needed to accelerate change and ease the transition?  Please add your comments below; I’d like to hear from you.