Applying the lessons learned in other industries to health care

While grappling with the costs and imperfections of our health care system in recent years, a multitude of experts in the field found it useful and enlightening to compare health care to a variety of more familiar industries, and to suggest that health care should adopt operational models that have been shown to work well in those other industries.

From the financial industry, we learned that health care must be computerized. From the restaurant industry, we learned that health care must be standardized. Observing Starbucks, we concluded that clinicians must be taught a few things about customer service. Aviation brought us safety manuals for medical procedures, and NASCAR informed us about the superior power of disciplined teams of workers. The history of agriculture provided important lessons on government’s role in creating bigger and more efficient producers, and from the history of manufacturing we learned everything else we needed to know, from Six Sigma to lean Toyota to focused factories, and how innovation must begin with cheap products and services that are good enough for all but the wealthy and the narrow minded.

As many of the lessons learned from these industries are being applied to health care, the results are starting to come in and most are shockingly disappointing. A group of researchers from Stanford University is reporting in the May issue of Health Affairs that “an increase in the market share of hospitals with the tightest vertically integrated relationship with physicians — ownership of physician practices — was associated with higher hospital prices and spending.”  A Harvard University paper in the same issue of Health Affairs is predicting that “ACA reforms could result in an additional 4.4-percentage-point increase in profit margins for hospital-based EDs compared to what could be the case without the reforms.” A very large study in Canada recently published in NEJM, found that “[i]mplementation of surgical safety checklists in Ontario, Canada, was not associated with significant reductions in operative mortality or complications.”  And yet both vertical integration and ACA reforms are continuing at a brisk pace.

Back in 2012, a large national study from UC Davis, published in JAMA Internal Medicine, found that “higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.” A more recentJAMA Surgery study from Johns Hopkins “suggests that patient satisfaction is not related to standard process-of-care measures that have long been used as markers of surgical quality.”  Also in JAMA Internal Medicine, researchers from the University of Chicago reported that in their study “71.1% of patients preferred to leave medical decision making to their physician” and the remaining 28.9 % of patients who preferred to make their own decisions “had increased LOS of 0.26 day and increased costs of $865.” Patient experience surveys are quickly becoming mandatory and the “patient decision aids” industry is booming.

Yes, the findings in almost every article cited above have been disputed, and a few generated notable literary altercations, none more acrimonious though, than the technology wars. Two years ago a study funded by the Agency for Healthcare Research and Quality (AHRQ) found that physicians in hospitals spent approximately an hour and a half each day interacting with EHRs, and that 16% of their notes along with 38% of nursing notes were never read by anybody. A year later, the American Journal of Emergency Medicine published a study showing that great strides have been made, and in the ED, 43% of physician time was spent interacting with EHRs and 28% was spent interacting with flesh and blood patients. A fascinating new paper from researchers at Northwestern University studied the gazing patterns of doctors during office visits and found that “physicians with EHRs in their exam rooms spend one-third of their time looking at computer screens, compared with physicians who use paper charts who only spent about 9% of their time looking at them.” The market for analyzing all the data collected in lieu of patient care is “poised to skyrocket” from the current $4.4 billion to well over $21 billion by 2020.

In a hot off the presses opinion piece in JAMA Internal Medicine, paid for by a charitable organization controlled by Sutter Health, the venerable Dr. Thomas Bodenheimer is advocating more substantive delegation of clinical tasks to medical assistants who, as a group, are “ethnically and linguistically diverse, and culturally concordant with a variety of patient populations” (I absolutely adore the English language), in order to meet increased demand for primary care and allow clinicians to “see more patients per day.” Predictably, Dr. Bodenheimer concludes that the “enhanced roles for medical assistants is an innovative approach.”

Another innovation that is so new and exciting that University of Chicago researchers decided to write a Health Affairs paper about it even before study results were available, consists of primary care doctors who will be admitting and caring for their own patients when hospitalized. The grand innovation here seems to be that patients must first become very sick, presumably for lack of proper medical care, and then and only then, do they get a comprehensive care physician to follow them through the numerous hospitalizations awaiting them. It is comforting to read that this oddly retrograde approach is not posing any theological difficulties with the Holy Scripture of health care reform – The Innovator’s Prescription – which is the embodiment of all we need to learn from retail, manufacturing, technology, etc.

There is no need to shake your head in utter disbelief, because there are very simple explanations to this cacophony of Casino style fun and games, where we all serve as chips and tokens. Yes, money is one explanation, but not the only one. It seems that in a headlong rush to fix things, many people with basically good intentions overlooked a few salient linguistic details.

First, the Marx-Schumpeter paradigm for capital accumulation is called “creative destruction,” not destructive creation, which means that before you take the wrecking ball to what is already there, you must have the new and tremendously improved stuff, working and spreading like wildfire.

Second, “disruption” is a retrospectively affixed label to a novel business idea that worked surprisingly well, not a prospectively self-ascribed title used for everything people do after they have coffee in the morning.

Third, business models conceived with an intention to defraud the public are commonly referred to as embezzlement, corruption, larceny or felony in general, and only rarely are they hailed as “innovations.”

With so many divergent opinions on what ails health care and how to best provide a cure, can we maybe start by agreeing on the terminology we use to disagree with each other?

Margalit Gur-Arie is founder, BizMed. She blogs at On Healthcare Technology.

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  • Dr. Drake Ramoray

    I agree with everything in this article except “many people with basically good intentions………” All of this healthcare reform not supported by most doctors is achieving exactly what it was designed to do. Minimize the role of doctors, shift the money and resources to hospitals, admin, pharmaceutical companies and big insurance. None of this was intended to “improve” patient care. The real million dollar question is why do so many doctor societies go along with this sham.

    I just withdrew my membership from the Endocrine Society as they have developed a subcommittee for PCMH/ACO who wants to address Health disparities through pay for performance and patient satisfaction.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Well, I have to assume that at least some of the doctors actively working, speaking and otherwise promoting “change” are well-intentioned, and that a good amount of non-physicians are supporting these things because either they don’t understand health care, or they don’t understand the true drivers.

      Frankly, I am mystified by the doctors….. And it’s not just the ones who are largely in administrative positions, but also many rank and file who are going along with all of this, sometimes enthusiastically. Are we maybe missing something?

      • Dr. Drake Ramoray

        We are clearly missing something, but I don’t know what it is. If I had the sociology credentials it would be my area of study, maybe a back up plan if this whole doctor gig doesn’t work out.

        • Arby

          For the sociology of it, a physician on another board recommended the book Systems of Survival by Jane Jacobs. From Wiki, the book “…describes two fundamental and distinct ethical systems, or syndromes as she calls them, that of the Guardian and that of Commerce”. I haven’t read it yet, but it is on my list.

          From my personal observations, I think the well-meaning, enthusiastic crowd in medicine just adopted the terminal optimism that pervades the business world. Think Stepford Wives.

          One of my more memorable conversations:

          Me: Now that x happened, I hope that Marketing can reduce the number of last minute changes in their project requirements and Technology can remove some of their ponderous procedures.

          Stepford Wife: Yes, that would be nice. But, we always get things done no matter what.

          Me: Yes, we do, after developers and testers work 17-24 hour days as the deadline approaches. Do you remember our last big implementation when we had the 36 hour check-out call?

          Stepford Wife: Yes, well we are trying to make it better. We are recording the hours of everyone to see who works the longest hours so that we can find ways to reduce their workload.

          Me, thinking loudly but not speaking it: Yes, you are tracking the hours of those that work too many hours so you can get on them about how inefficient they are and tell them they need to work smarter, not harder.

          See what I mean?

          • Dr. Drake Ramoray

            Very accurate assessment. I will put the book one reading list.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Great reference… I will look it up…

      • doc99

        And they call Medicine a “Learned Profession…”

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          not for much longer :-(

      • guest

        For me it is med school debt. Pay is still relatively high which will allow me to pay it off in a few years. In the mean time I continue looking for other career options outside medicine. Once our pay declines, it will be much easier for many physicians to look for ways out. The level of disrespect, micromanagemnt, lack of trust and manipulation is only going to increase.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Yes, debt is a fantastic instrument to keep young people graduating from universities in indentured servitude to job creators. By the time all debt is paid off, they have a family to support and brand new (and crushing) financial responsibilities to their children, so servitude continues unabated. It almost looks like an invisible hand is orchestrating this stuff…. :-)

          • guest

            …and slowly but surely destroying all that is humane and civilised in medicine and the world. I believe we as human beings should strive for more than only profit.

      • Joe

        There are always useful idiots.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Yes. I was hoping some other explanation though… something more cheerful and optimistic that I might have missed…. :-(

    • DeceasedMD1

      Wow Drake. And here I was thinking that at least there was one good medical society that is respectable. So now endo is joining in? I don’t blame you for dropping them. What do you think happened that changed them?

      • Dr. Drake Ramoray

        Endo Society is an international society and so has already had universal health care etc tendencies. Just seem to be jumping on the band wagon to corporatist American health care.. AACE remains the sole hold out. Some rumblings from those involved in hospital systems and such but no societal push. They are the last stand at this point, only a matter of time I suppose. I feel like a dinosaur in terms of how I think medicine should be practiced. Just add myself to the list of docs whose views aren’t represented. Sad really.

        • DeceasedMD1

          Funny Drake you should say that. I feel also like an extinct dinosaur. It is devastatingly sad to me that pts are seen with barely any history taken even by a medical student, they have no real relationship with a physician in CorpMed, but are getting ready for the next procedure and a call for the next satisfaction survey. It is truly sad. The valued relationship is gone and we are left with a robot EHR taking over.

          • DoubtfulGuest

            Also, please feel reassured that many patients prefer their dinosaur docs and the dinosaur model of care. :)

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Do they? Perhaps they need to be a bit more vocal about those preferences…. Just sayin’….

          • DoubtfulGuest

            Fair enough. What’s the best way to do that, do you think?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            We’ve been down that road before on this blog, haven’t we? :-)

          • DoubtfulGuest

            Please bear with me Margalit, it’s one of my slow days. I don’t recall that there was ever any consensus about what would be helpful from the patient end. So, what sort of response were you looking for from me?

          • Rob Burnside

            You’ve hit on a key point, DG. Satisfaction surveys are often designed to give a desired result–if nothing else, the impression that “someone cares.” They’re just an unfortunate fact of life nowadays. My sense is that no one is really looking at things from the bottom up, other than those of us at the bottom–consumers (formerly called “patients”). But I sincerely hope I’m wrong.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I wasn’t looking for specifics, but Rob is right. I don’t know that “consumers” can do much in this brave new environment….

          • EmilyAnon

            Actions speak louder than words. If I have a choice I’ll pick the dino-doc.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Perfect!! Here is a small anecdote you may find interesting:
            I was in a meeting recently and someone asked people what they would want most from a primary care “provider”. The answers were: someone that listens, someone that knows me, someone that cares, not to wait a long time, has all my information…. etc.
            But here is the catch: all these people are assuming competency, education, expertise – so they don’t even mention it. And this type of “research” is what we base our policies on, when we decide that any “nice” and “compassionate” person, armed with a database can substitute for Dr. Dino perfectly well….
            I actually asked one of the responders after the meeting if she would be fine with me “providing” her care, since I listen well, care for her a lot and can Google pretty much whatever I want about her….

          • DoubtfulGuest

            Margalit…Emily is right AND it’s complicated. Does dino-doc = private practice non CorpMed doc? I went to those for a long time. They were the ones who told me I needed a teaching hospital. For some diseases there is no choice. That decision was made by the docs, not me. I remain interested in the plight of private practice docs and I care about them even if I never meet another one in person.

            Are dino docs hurting for patients anyway? Isn’t the real competition to find a doctor who’s willing to see us? So, what are specific ways we can help fight these practices that are hurting all our docs?

            We’ve heard that a patient satisfaction survey that’s anything less than perfect can be used as a weapon against our doctors. So, would it help to write hospital admin and the survey companies? To say these surveys are full of it and if I ever had an issue with a doc it would be dealt with only in a private conversation with the doc ? I’ve thought about that, but wasn’t sure if it could have any negative impact on my physicians, since the “system” would know who I see. I’m willing to do whatever would help.

          • DeceasedMD1

            Aye and there’s the rub as Shakespeare would say. For complex specialty issues pts can need an academic center. Unfortunately welcome to CorpMed. I am not sure a way around that.

          • DoubtfulGuest

            Yes — GREAT docs, icky CorpMed. No, no way around it, but surely some way to help even so. I’m not sure why there’s any confusion about my question, actually. I go where the private practice docs told me to go, and…there I am. Many CorpMed docs are dino docs in their hearts, still. They and I place importance on the same things.

          • Patient Kit

            Some of the best docs I’ve ever had are teaching hospital-based docs in spite of the Corp Med system within which they work, the specialists anyway. I mean, really excellent doctors, both in education, experience, cutting edge skill and in compassionate communicative personality. Even understanding the profit-driven corporate pressures they work under, I’m not going to condemn all hospital-based doctors as being worse than private practice doctors.

          • Dr. Drake Ramoray

            There was a study some years ago (over ten years and I can’t find it) that showed te exact answers you provide for primary care. When the same question was asked about specialists it was, training, competency, intelligent, miss the write diagnosis and other more qualifications type items. An interesting dichotomy, but I’m not aware of more recent research on the topic.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I wonder why this is…..

  • ninguem

    Cheesecake Factory?

    • Dr. Drake Ramoray

      No mention of Malcolm Gladwell

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Needed to save some stuff for future blogs :-)

  • LeoHolmMD

    “an increase in the market share of hospitals with the tightest vertically integrated relationship with physicians — ownership of physician practices — was associated with higher hospital prices and spending.”
    Someone should learn from the great pyramids, how to identify pyramid schemes.

  • LeoHolmMD

    “higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.”
    Why are we letting patients die needlessly from satisfaction, when it is completely preventable?

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      This is actually a great question with a complex answer. There is a glut of “industry research” that is usually not peer reviewed, but sometimes it is masquerading as proper research in respectable journals, and the only way to figure things out is to track authors affiliations, partial disclosure forms, former and future employment and funding for the “research”.
      Some of these pieces are brazenly labeled “editorials” and all make frequent use of the terms “we believe” or “it is our belief”, in the obligatory closing paragraph that advises “policy makers” and “stakeholders”.
      Every piece of research that results in numbers that do not support the official line are then debated (ferociously in many cases) based on these industry marketing materials. The goal I think is to create the impression that we don’t really know anything for sure and “further research is needed”. It works really well.

      • LeoHolmMD

        Medicine needs an “establishment clause”.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          …and a “free exercise” clause for physicians…

  • IFINDITODD

    this person always writes good articles. Agree – but many MD’s could see this coming – just weren’t listened to. The moneyed interests carry the day.

    And I agree with Drake Ramoray that they are not well-intentioned – but it makes a nice hat-tip.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Thank you. It’s not just MDs that could see it coming. The first blog post I wrote over 5 years ago when these top-down changes began taking shape was a plea to have practicing doctors do the planning, or at least have a voice in it, instead of the usual suspects. Of course, nobody listened and I didn’t really expect them to. I know some of these folks, and they are convinced that they are acting for the public good, which does not make them less dangerous, and perhaps even more so….

      • Arby

        I believe even more so. The business minded will cut and run to more lucrative pastures if they face opposition they think they cannot overcome. Yet, I fear that the true believers will fight all the harder. Except that with true believers you at least stand the chance of convicting them with evidence that what they are doing is causing more harm than good.

  • dontdoitagain

    Margalit, we just got the news that in order to renew our commercial licenses we must get the “new and improved” medical examination. I’m not sure what the government hopes to accomplish with this, as my doctor assuredly can give me a physical, AND I’ve been getting them every two years, from my doctor, whether I need them or not since the inception of this requirement. NOW however my doctor can no longer do these driver exams until he or (sinisterly) his PA, NP or whatever low level practitioner he has goes in for additional training. Of course, this being a government mandate and all, nobody had received this “additional training” when the law took effect. I know I called every single walk in outfit and my own GP to get my exam done and NOBODY has gotten the “training” for my medical card requirement.

    I don’t like nurses or pa’s since an unfortunate incident years ago. Nobody asked me what my patient satisfaction was with uppity advance practice nurses… I feel like I’m living in the twilight zone. So now is the government going to require yet another layer of snarky nurses to perform NOTHING BUT commercial drivers exams? So we have yet more expense related to health care? It’s already $100 for the exam, (not covered by any insurance in case you are interested, but birth control pills are) what will it be when these people finally get the oh-so-necessary “training”? I don’t even want to start with the expensive bi-annual FBI background checks to prove that I haven’t suddenly become an undesireable at my advanced age.

    The only good part about this is that I tried to get my exam EARLY! I guess I’d be out of a job if I had waited until the exam was due. Hoping that it still isn’t too late to keep my job. After all, if nobody is getting the stupid “training”, they yank my license the minute that medical card expires. No license, no job. Did anybody in the government give a damn?