Gawande and Berwick on Why Reform Legislation Cannot Lay Out a “Master Plan” – Part 2

Boston surgeon Atul Gawnde and Don Berwick, the president of the Institute for Health Care Improvement, understand that we can create a sustainable, universal U.S. healthcare system only if we reduce costs. And they recognize that by spending less, we can, in turn, lift the quality of care. As Berwick puts it: “The best health care is the very, very least healthcare that we need to gain the long and full and joyous lives that we really want.”

Talk to virtually anyone who has studied the problem in depth, and they agree. While many uninsured and underinsured patients receive too little care, a great many well-insured patients—including Medicare patients—receive too much of the wrong kind of care. Gawande explains: “Our system neglects low-profit services like mental-health care, geriatrics, and primary care, and [is] almost giddy in its overuse of high-cost technologies such as radiology imaging, brand-name drugs, and many elective procedures.”

It’s remarkable how those who have investigated reform agree.  It’s not that we don’t know what to aim for. We’re just not at all sure how to achieve those goals in a profit-driven health care system.

Gawande and Berwick argue that we’re not going to find out until we enact legislation. Congress cannot sketch out a solution on paper. The only way to realize reform is to pass a law—and then engage in the very messy process of trying it out on the ground. 

It’s remarkable how those who have investigated reform agree.  It’s not that we don’t know what to aim for. We’re just not at all sure how to achieve those goals in a profit-driven health care system.

Gawande and Berwick argue that we’re not going to find out until we enact legislation. Congress cannot sketch out a solution on paper. The only way to realize reform is to pass a law—and then engage in the very messy process of trying it out on the ground. 

Reading the Minds of Millions of Americans

To predict, with any certainty, which reform strategies will work and which won’t requires reading the minds of the millions of patients, health care providers, hospital CEO’s and manufacturers involved in our health care system. Which incentives will change how they think and how they act? Which will they ignore?

This is a huge country. Ideas that work in some areas won’t find an answering chord in others.

How many patients will respond to rational appeals to self-interest? Economists are virtually the only social scientists who believe that men normally act in their own self-interest. Sociologists, anthropologists and, of course, psychologists know better. The fact that we are often irrational in our response to seemingly logical ideas makes us unpredictable. Interesting. Amusing. Great material for a novel. But as difficult to forecast as the weather.

If we hope to “bend the curve” of health care inflation, the web of relationships that connects patients, doctors and hospitals will have to be transformed. And no one can do this except the individuals themselves. Patients, nurses, doctors, and hospital CEO’s must begin to look at each other through a different lens. This takes us into relatively unknown territory: the human mind.

In short, “bending the curve” means changing the social model—i.e., moving minds. For example, hospital CEO’s need to recognize that they are not running revenue centers. They are running cost centers. Their goal, under reform: to trim hospital bills. This means reducing revenues. How do we bend their minds?

“We have our models, to be sure,” Gawande writes. “There are places like the Mayo Clinic, in Minnesota; Intermountain Healthcare, in Utah; the Kaiser Permanente health-care system in California; and Scott & White Healthcare, in Texas, that reliably deliver higher quality for lower costs than elsewhere. Yet they have had years to develop their organizations and institutional cultures. We don’t yet know how to replicate what they do. Even they have difficulties. Kaiser Permanente has struggled to bring California-calibre results to North Carolina, for instance.”

This doesn’t mean that there is something wrong with Kaiser’s structure. It just means that it’s not a “master plan.”  Nothing could be. There is no “Toyota” diagram of efficiency for healthcare.  Healthcare isn’t about producing automobiles; it’s about repairing human beings. This means that an enormous number of cultural traditions and religious beliefs come into play. As Gawande points out:  “Each area has its own history and traditions, its own gaps in infrastructure, and its own distinctive patient population.”

I am not suggesting that we should accept regional variations that expose some patients to over-treatment, while expecting taxpayers in other parts of the country to pay for it. Reformers must take a close look at individual hospital systems, and the web of doctors who refer patients to those hospitals, finding ways to steer them toward the sustainable, affordable, effective care that their patients need.
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 Last week, Berwick offered a definition of optimal care that every corner of the country needs to keep in mind when he suggested that “The best health care is the very, very least healthcare that we need,” and explained: “The best hospital bed is empty not full. . . The best CT-scan, the one we don’t need.”

The health care industry, like all businesses, wants to grow. But as a society, we cannot afford to foot the bill for a system in which each player strives for higher revenues and fatter profits. As Berwick puts it: “We have to escape from the tragedy of the commons—and the instinct to simply grow what we have, to do what we do”.
 
That said, different strategies will work in different regions. Accountable care organizations may not work in the corridor that runs from Boston to Washington, where so many physicians work in small practices. Very likely they will have to find other ways of pooling resources.

This is why reducing the cost of care does not admit to a single solution. The most meticulous master plan, carefully “scored” and laid out on paper, is meaningless, unless it moves hearts and minds--and thus transforms our extravagant, inefficient and extraordinarily solipsistic health care system.

The only way to find out what will work is to enact reform. This is why Gawande believes that “We will have to proceed by trial and error with a ‘hodge-podge’ of pilot projects.

Turning to history, Gawande offers an analogy, arguing that U.S.  health care reform can be compared to  agricultural reform.  “In 1900, more than forty per cent of a family’s income went to paying for food. At the same time, farming was hugely labor-intensive, tying up almost half the American workforce. We were, partly as a result, still a poor nation. Only by improving the productivity of farming could we raise our standard of living and emerge as an industrial power. We had to reduce food costs, so that families could spend money on other goods, and resources could flow to other economic sectors.”

At the time, he argues, the cost of food was overtaking the economy, just as the cost of health care is encroaching on GDP today.

Comparing Health Care Reform to Agricultural Reform?

I have some reservations about how well the analogy works. But analogies and similes (X, is like Y) always involve a stretch. That’s why I prefer metaphors and symbols ( X is embedded in Y; it’s implicit, not explicit.)

Nevertheless, from 1903 (when Gawande’s story about the history of U.S. agriculture begins), to the middle of the 20th century, there is no question that county extension agencies helped improve farming practices. Sometime after that, I would argue, corporations began to take over agriculture. And the government began to serve corporate interests.

That said, Gawande is right to argue that earlier in the 20th century, “the government shaped a feedback loop of experiment and learning and encouragement for farmers across the country.”  If a comparative effectiveness panel began disseminating guidelines for best practice, while simultaneously soliciting feedback from physicians, nurses and hospitals, it could create a similar learning loop for medicine.

Engaging the farmers was not always easy. Like physicians who bristle at the idea of “evidence-based medicine,” or “cook-book medicine,” farmer’s resisted progress—what they called “book farming.”

Here, Gawande underlines another lesson that we need to remember as we embark on health care reform:  Doctors, nurses, hospital administrators and other healthcare professionals will have to re-form health care at a grass roots level. They must “own” the process. Otherwise they won’t believe in it. He quotes Seaman Knapp, an early pioneer in agricultural reform:  “What a man hears he may doubt, what he sees, he may possibly doubt, but what he does himself, he cannot doubt.”

In August, I wrote about ten U.S. communities that have discovered that it is possible to change how care is delivered, making it both less expensive and more effective.

They didn’t have to ration care to reduce costs. They don’t have to pay more to achieve better care. How did they do it? Local health care providers got together and decided that, instead of competing, they would unite. Most of these communities moved away from fee-for service care. One began pooling fees. Finally, they began “counting”—keeping track of the medical resources they were using—with the aim of reducing waste.

Whatever happens in Washington in the next month, these communities are already in the vanguard of reform. Berwick believes that the government can declare that universal coverage is the law of the land. This would mean that, as a civilized society, we have decided that we cannot deny anyone humane, effective care. Government can lay out rules that oversee health care for all: the sick cannot be penalized for being sick; everyone must participate, or pay a penalty.  And Washington can figure out how to funnel funding to universal care.

But, as a society, Berwick points out, we cannot afford unlimited care. If universal care is going to be sustainable, the system must change from within. That’s why it has to happen on the ground.

In his keynote address, Berwick offered his audience an opportunity: “I challenge us to end the “Tragedy of the Commons” in health care. I challenge us to prove Garrett Hardin wrong.”

I submit that Garrett Hardin was wrong. It is not inevitable that human beings must be short-sighted and stupid. We are not doomed to “tragedy” or “ruin.” In some parts of the U.S., as well as in other countries, people have learned to think collectively about health care.

“It isn’t easy,” Berwick admitted to his audience. “Positive collective action, even in small communities, and especially in health care, is fragile. It could all just fall apart. But, it can work. I know it can work because, sometimes, some places, it does work.

“But,” he added, “I’m very mindful of who you all are. You are doctors and nurses tending patients, operating managers trying to keep 6 West going or clear the waiting lines. You’re QI directors coaxing the operating room into using a checklist, or executives getting ready to tell the Board some bad news. And, I think, you’re wondering, ‘What can I do from my limited perch to govern the Commons better? I’m already over my head.’

“I am really not sure,” Berwick added. “But, I have a strong feeling that it can – it has to – start with you. Command and control solutions seem weaker every day . . . Maybe someone smart enough and courageous enough in Washington can write a few rules that change the odds . . .  But, the odds of real reform, ‘re-form,’ remain zero – the Commons is doomed – unless the action is closer to home – closer to you.”

Berwick then offered some suggestions:

•  “Adopt an aim. Here’s one: Over the next three years, reduce the total resource consumption of your health care system, no matter where you start, by 10%. Do this without a single instance of harm, rationing of effective care, or exclusion of needed services for the population you serve. Do it by focusing not on the habits of health care as it is now, but by focusing on what really, really matters.

•  “Develop, fast, because there isn’t much time left, your own institutional structures – the ones you will need for local rule-making to better manage your Common Pool Resource. Do not wait for external rules to be made, or to change; do it yourself.

“One such structure might be, for example, a Community-wide board – the collection together of all the health care Boards with shared stewardship of the whole.

•  “Develop, fast, because there isn’t much time left, monitors, so that you can track the use of the common resource, and find out who is sticking to the rules you write, and who is breaking them   “And, when people do break the rules – opportunists, free riders – create undesirable consequences for them, if you can, and ways to isolate them, if you cannot. Collective action is very fragile. You will need militia.”