Gawande and Berwick On Why Reform Legislation Cannot Lay Out A “Master Plan”

“Where is the plan to make health care affordable?”

“I want to see the savings.”

“Show me the money: Lay it out in simple language-- on one page.”

Critics of health care reform legislation have become increasingly adamant on one point: They want to know how reformers are going to rein in the skyrocketing cost of care. And they want to know now. They’re not interested in “pilot projects,” or proposals that they refer to as “reform lite.” They want a proposal that the Congressional Budget Office can “score,” tallying up the savings the way one might add up the points in a tennis match, neatly, definitively, without argument.

In the most recent New Yorker (December 14), Dr. Atul Gawande faces down the critics. In seemingly effortless prose, he cuts to the heart of the matter: the uncertainty that haunts any human endeavor that aims at changing the culture. While most pundits who talk about health care reform focus on the day-to-day political debate, this Boston surgeon steps back and puts health care reform in a larger context: human history.

“Where is the plan to make health care affordable?”

“I want to see the savings.”

“Show me the money: Lay it out in simple language-- on one page.”

Critics of health care reform legislation have become increasingly adamant on one point: They want to know how reformers are going to rein in the skyrocketing cost of care. And they want to know now. They’re not interested in “pilot projects,” or proposals that they refer to as “reform lite.” They want a proposal that the Congressional Budget Office can “score,” tallying up the savings the way one might add up the points in a tennis match, neatly, definitively, without argument.

“There are, in human affairs,” he tells us, “two kinds of problems: those which are amenable to a technical solution and those which are not.”  When it comes to “reforming the health-care system so that it serves the country’s needs”—and provides affordable, high quality care for all, Gawande warns “there is no one time fix. No nation has escaped the cost problem. Nobody has found a master switch that you can flip to make the problem go away. This cannot happen by fiat. If we want to start solving it, we first need to recognize that there is no technical solution.”

Why can’t we find a single, elegant, rational solution? Because what we are facing is neither a scientific problem, nor a mathematical conundrum. This is not physics. We’re not looking for a breakthrough formula.  What we are attempting is to transform the nation’s medical culture--to change how millions of patients, doctors and others involved in this $2.6 trillion industry think about healthcare and their relationship to the system. Inevitably, this will be messy.

As White House budget director Peter Orszag recently reminded us, the process will take ten years –or longer.

At a time when Washington seems on the verge of handing health care reform over to the private insurance industry, I find this fact oddly comforting. The truth is that what happens in the coming days, weeks, or months will not determine the final shape of health care reform. What happens over the next decade—and beyond—will. (Though I also recognize that if the legislation we pass now is so weak that it implodes, it could set the reform process back by many years.)                                       

The Problem Reformers Face

Many Americans assume that health care costs have been levitating in recent years because the science of medicine has been advancing so rapidly. But, as Gawande points out, that just isn’t true.

Over the past ten years, there have been “no great strides in service” in our health care system, Gawande observes. While health care systems in Europe have managed to “install electronic medical records and offer after-hours care, we have made little progress in either area.”

Moreover, and most importantly— “improvement in demonstrated medical outcomes has been modest in most fields.”

Nevertheless, over the past decade: “The average annual premium for employer-sponsored family insurance coverage rose from $5,800 to $13,400. Those skyrocketing premiums reflect the fact that over the same  span, the amount that private insurers paid out to hospitals, doctors and patients has climbed by an average of 8 percent a year, year after year.  Insurers’ reimbursements have more than doubled.

Yet-- we are not safer or healthier.  We are just paying more.

The cost of health care has headed for the heavens because our system is so inefficient, “fragmented, disorganized, and inconsistent,” Gawande explains. “It’s neglectful of low-profit services like mental-health care, geriatrics, and primary care, and almost giddy in its overuse of high-cost technologies such as radiology imaging, brand-name drugs, and many elective procedures.”

Cultural change will involve re-shaping how both patients and doctors view those high-cost technologies. Physicians are just beginning to counsel patients that cutting-edge medicine carries risks as well as benefits. Trimming some of the waste from the system means sharing decision-making with patients, acknowledging the pros and cons of tests and treatment, and admitting that, for many illnesses, we have no definitive answers. Spending more won’t bring the answers. Often, the way forward is to gather, sift and consolidate the medical evidence that we have. Under reform, electronic medical records can help collect the data, and panels of physicians can draw up guidelines (not rules)-- but medicine will remain shot through with ambiguities.                                 

The Size of the Problem: A $2.6 Trillion-Dollar Industry

Patients and physicians are only part of an enormous medical-industrial complex that we have built up over the last three decades. “Medicine involves hundreds of thousands of local entities across the country,” Gawande writes “hospitals, clinics, pharmacies, home-health agencies, drug and device suppliers. They provide complex services for the thousands of diseases, conditions, and injuries that afflict us. They want to provide good care, but they also measure their success by the amount of revenue they take in, and, as each pursues its individual interests, the net result has been disastrous.”

That last sentence is key.  More than half a century ago, this nation made the choice to turn medicine into a largely unregulated for-profit industry. Thus, we entrusted health care to the laissez-faire chaos of a fiercely competitive marketplace.

What is at stake, after all, is more than $2.5 trillion in health care dollars. But in a nation where more than 16% of the population is uninsured, not everyone can pay their bills. The result, in many cases, is a Hobbesian competition for the well-insured, a war of one against all that pits hospital vs. hospital, hospital vs. doctor, doctor vs. doctor,  doctor vs. hospital, drug-maker vs. drug-maker.

Over the past two decades, we’ve seen turf wars between specialties, and medical arms races among hospitals, all rushing to buy the same exorbitantly expensive equipment--equipment that they might better share. Patients could go to the outpatient clinic at hospital X for the latest in MRI’s,  go another outpatient clinic for a different test. Drug-makers scrambling for customers spend billions on pharmaceutical ads, money that does not add to the value of the product, but does help ratchet up the price of drugs. Those large drug companies do not share research. Too often, even hospitals are reluctant to share patient records.

Meanwhile, patients battle for their right to care at the lowest possible cost. But they are wary of being forced to pay for others.  Some say: “I’m willing to pay for my mother, but I’m not willing to pay for someone else’s mother.”                             

A Competitive System Headed Toward Ruin

Last week, at the Institute for Health Care Improvement’s (IHI) 21st Annual National Forum on Quality and Improvement in Health Care, in Orlando, Florida,  IHI president Don Berwick described how, as each coalition in our health care system pursues its self-interest, we destroy our chances of achieving true health care reform. “Name any stakeholder – hospital, physician, nurse, insurer, pharmaceutical manufacturer, supplier, even patients’ groups – every single one of them says, 'Oh, we need change! We need change!'” Berwick observed. “But, when it comes to specifics, every single one of them demands to be kept whole or made better off.”

“We are stuck,” he declared, ‘in ‘the Tragedy of the Commons.’”

Berwick briefly recounts the story of the Commons, originally told by Garret Hardin in an article that appeared in Science magazine back in 1968:  “Hardin imagines a pasture that is held in common by the community. Anyone in the community can graze his sheep on that pasture. There is, of course an optimal number of sheep to graze on the commons.”  If too many are loosed on the grass they will destroy the pasture.

Hardin asks:  “What does a rational person do?

Berwick provides the answer: “Add sheep. Everybody adds sheep.” After all, Berwick points out, “Anyone who voluntarily limits his herd is a chump, a sucker—He’s just giving up what everyone else is getting.”

Hardin concludes: “Therein lies the tragedy. Every man is locked into a system that compels him to increase his herd, without limit, in a world that is limited. Ruin is the destination toward which all men rush.” I would add that this is a near-perfect description of how competition destroys value.

Berwick elaborates: “The smart strategy for each person separately is not the best strategy for all people together. What is good for ‘me’ is not good for ‘us.’ Just like the villagers, health care stakeholders are eroding a common good by doing what makes sense for each of them, separately. In the short run, everyone wins. In the long term, everyone loses.”                           

What is Required: Grassroots Collaboration, Trial and Error

Yet, Gawande points out, we have a system designed to separate us. Our fee-for-service system fosters fragmentation and discourages collaboration. By “doling out separate payments for everything and everyone involved in a patient’s care, it has all the wrong incentives. It rewards doing more over doing right. It increases paperwork and the duplication of efforts, and it discourages clinicians from working together for the best possible results. Knowledge diffuses too slowly. Our information systems are primitive...”

And the best way to fix this wildly inefficient system in which everyone pursues his own short-term interest?  “Well, plenty of people have plenty of ideas,” Gawande writes. “It’s just that nobody knows for sure.

“To figure out how to transform medical communities, with all their diversity and complexity, is going to involve trial and error,” he adds. “And this will require pilot programs—a lot of them.”

“Pick up the Senate health-care bill—yes, all 2,074 pages—and leaf through it,” Gawande suggests. “Almost half of it is devoted to programs that would test various ways to curb costs and increase quality. The bill is a hodgepodge. And it should be,” he declares. We cannot expect Congress to lay out a master plan.

In his speech last week, Berwick made a very similar point, noting that “last summer President Obama seemed to shift his wording, from “health care” reform to “health insurance” reform.  Some criticized the president, but Berwick says, “I think he is being accurate.  Congress is aiming for health insurance reform—better coverage, changes in the funding and rules for coverage. Getting everyone covered is right, is moral. We ought to pass that law,” he added.

“But,” Berwick emphasized, “that doesn’t change care. It doesn’t make it any better, or any more valuable, or any more affordable. . . It doesn’t make it better.  We need a new system of care.” In other words, we must change how care is paid for and how it is delivered.

“Congress hasn’t led us to a new system of care. And I don’t think it will,” Berwick declared.  “Congress won’t give America even a vague prescription, let alone a detailed set of rules.”

Why not? Because, as I have suggested in the past, legislators are not physicians, they are not nurses, they are not medical researchers. And only someone with hands-on experience can appreciate the diversity of patient needs in different parts of the country. Health care should not be organized around “doctors’ druthers” or “this is the way we have always done it here.” But if it is going to be patient-centered, it does need to respond to differences in the patients’ cultures.

“How could Congress possibly know enough to specify for every community, the exact design for care that is safe, effective, timely, patient-centered, equitable and sustainable?” Berwick asked.

The legislation does contain long sections “focusing on quality,” Berwick acknowledges, and there legislators lay out possibilities. But it is up to health care communities to test, adapt and perfect these strategies in real world.

Gawande offers examples: “The bills suggest testing a number of ways that federal insurers could pay for care. Medicare and Medicaid currently pay clinicians the same amount regardless of results. But there is a pilot program to increase payments for doctors who deliver high-quality care at lower cost, while reducing payments for those who deliver low-quality care at higher cost. There’s a program that would pay bonuses to hospitals that improve patient results after heart failure, pneumonia, and surgery. There’s a program that would impose financial penalties on institutions with high rates of infections transmitted by health-care workers. Still another would test a system of penalties and rewards scaled to the quality of home health and rehabilitation care.

“Other experiments try moving medicine away from fee-for-service payment altogether. A bundled-payment provision would pay medical teams just one thirty-day fee for all the outpatient and inpatient services related to, say, an operation. This would give clinicians an incentive to work together to smooth care and reduce complications. One pilot would go even further, encouraging clinicians to band together into ‘Accountable Care Organizations’ that take responsibility for all their patients’ needs, including prevention—so that fewer patients need operations in the first place. These groups would be permitted to keep part of the savings they generate, as long as they meet quality and service thresholds.”

“I believe that most of these are excellent ideas,” Gawande adds. “But I must admit, I don’t know which will succeed, or fail.”

In part 2 of this post, I explain why no one can know which ideas will succeed, explore Gawande’s argument that healthcare reform could be compared the way we transformed U.S agriculture, and consider Don Berwick’s challenge to his audience: “Prove Garret Hardin wrong.”