Health care efficiency can mean different things

Whether you’ve praised or vilified Obamacare, see it as an amazing achievement or an existential threat, it is the law of the land.  The price transparency created by online exchanges, a vital part of the law, stands to make cost the biggest driver of choice. This, along with cuts in government health spending, will disrupt the economics of health care in dramatic new ways.

Our first response to this brave new world is to declare that American health care needs to be more efficient. While this is not a new refrain, it is one being heard more loudly and urgently, from the office of the solo practitioner to the boardrooms of the most reputable hospitals and health care systems, than ever before. The Center for Medicare Services, the Institute of Medicine, and even the White House have endorsed the need for greater efficiency.  Employers and other payers want to factor efficiency into their decision about whether to use the services of a particular doctor, hospital or health care system.

But just what is efficiency in health care?  In many other industries, the answer is clear: produce or move more goods with the same or fewer resources (money, people, machines).   What turns out be both striking and surprising in health care, however, is that the term is a bit of a Rorschach test — prone to interpretation depending on who you ask and the lens through they view things.  Without a common understanding, any chance of making American health care better stands to stall.

I learned about this lack of clarity as I spent some time asking a variety of stakeholders  – both inside and outside of my health system — about what efficiency means.  Rarely were there two identical responses.  Physicians, those who see patients day to day in the trenches of their exam rooms, identified efficiency to be “less paperwork,” “more time,” or, for those who use electronic medical records, “fewer clicks of the mouse.” Some nurses I asked came back with comments about “patient ratios.”  Other health professionals had still other interpretations.  “Using technology to educate and help patients ‘own’ their health care decisions,”was one from a patient educator.

When I asked the question of those a little higher up the health care business food chain, the answers sharpened somewhat but were just as diverse. “Eliminate waste,”“do the right thing the first time,” “save money ““high quality service at affordable rates” were among them.  Finally, I took the time to ask some patients: “give me what I want or need,” “convenience,” “one stop shopping,” and “don’t keep me waiting” came back to me.

Why is it so hard to find agreement on the meaning of efficiency?  One reason is that we cannot agree what to measure. In a review of over 250 articles, a team of researchers found very little overlap among measures being used to measure efficiency.  Among any they did find, few to none have been subjected to rigorous evaluations to measure their reliability, validity, and sensitivity.  Finally, the researchers found very little overlap between any of these measures and measures of actual quality of care. Just as my informal poll of doctors, health care workers and patients found,  “the term efficiency is used by different stakeholders to connote various constructs.”

Another reason for our lack of agreement may have to do with the origins of the idea itself:  The concept of efficiency comes from a place that seems far removed from the internist’s exam room and the surgeon’s operating suite: the factory floor.  Efficiency was originally championed by the 19th Century management pioneer Frederick Winslow Taylor.  Taylor was steel factory machinist who saw who recognized that workers were not nearly as productive as they could be. He set about analyzing and scrutinizing their work habits so his factory could produce more widgets with a defined set of people and machines, the very definition of efficiency that we still use today.   He is widely credited as having launched management science and his career was loosely portrayed in the movie “The Efficiency Expert. ”

Attempts to translate this industrial view of efficiency to the world of medicine face resistance. There are no blue collar physicians.  We believe, by virtue of our ideals, education and rigor of our training, that our work cannot be standardized. A physician’s office, from reception to waiting to exam room is not an assembly line. Patients can’t and should never be seen as widgets to be moved along the floor.  On the contrary, we are professionals who use specialized skills (scientific and humanistic) to care for our patients. And even if each of those patients has the exact same problem, differences in their expectations, assumptions, values and a myriad of other factors make each non-interchangeable. Hence, the practice of medicine, a point of view that immediately casts doubt on the idea of efficiency among those on the front lines of medical care.

One solution to our dilemma is to acknowledge that (perhaps) efficiency is too insular a view.  Perhaps some rhetorical jiu jitsu, one which puts the patient out front, is a better approach.   Harvard Professor and health care thinker Michael Porter and former health care executive Thomas Lee hinted this recently: “Efforts to reform health care have been hobbled by lack of clarity about the goal … Narrow goals such as improving access to care, containing costs, and boosting profits have been a distraction,” they wrote in a recent article for Harvard Business Review.  Some of these items he mentions could easily be lay definitions of efficiency, like those folks gave me in my informal poll.

Porter and Lee offer a solution: To look outward by establishing a value agenda, one in which American health care moves away from a system organized around volume of visits, procedures and a system based what physicians do to one in which care is better coordinated around patients and the outcomes that matter to them, such as their time to recovery after illness, how sustained their recovery remains and their functional status, for example.  They outline 6 components to achieve this, which include organizing into integrated practice units, coordinating care across facilities, and moving to bundled payments for cycles of care.  While parts of these have certainly been established in various health care settings, any group that establishes the full complement of them will have a strategic advantage in the post-ACA world.

With their value agenda, Porter and Lee don’t jettison efficiency as much as they reframe it.  “At its core maximizing value for patients: that is, achieving the best outcomes at the lowest cost.”  This they argues, increases “the efficiency of providing excellent care.”  Thus, Porter and Lee turn the tables from an internally focused view where everybody agrees to disagree about — even abhor — the meaning of efficiency to one which those who truly have a patient-centered mission can set as a destination.  I’d be hard pressed to find a physician, non-physician colleague or patient who wouldn’t want to get there.

Rahul K. Parikh is a pediatrician and a writer.  He can be reached at his self-titled site, Dr. Rahul K. Parikh.

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  • QQQ

    “Whether you’ve praised or vilified Obamacare, see it as an amazing
    achievement or an existential threat, it is the law of the land.”

    ————————————————————————————————————–

    It’s not a tax. It’s a penalty. The drafters and supporters of the law,
    and even in big daddy government were adamant about this. They said the Interstate
    Commerce clause gave them the authority to impose this penalty.

    But wait a minute…

    A majority of the Supreme Court justices couldn’t justify the penalty
    under the Interstate Commerce clause. Justice Scalia famously said that
    the government was trying to create interstate commerce by mandate
    solely for the purpose of regulating it. Justice Roberts saved the day
    for the administration by declaring that the penalty WAS, in fact, a
    TAX, and that it was Constitutional under the federal government’s
    authority to tax wages. Never mind that the law is clear that it’s NOT a
    tax, and that while the IRS will collect the penalty, it cannot use
    it’s draconian collection authority to collect the penalty – it can
    deduct it from a taxpayers refund or ask the taxpayer nicely if they’ll
    pay it. They can’t impose any civil or criminal penalties on a taxpayer
    who refuses.

    But wait a minute…

    The law originated entirely in the Senate. The House didn’t change one
    word of the text. The reality is that they couldn’t. When the law passed
    the Senate the Democrats held a 60 vote majority, giving them enough
    votes to end any Republican filibuster. Before the House had a chance to
    take up the bill something extraordinary happened – Democratic Senator
    Ted Kennedy died, and the people of Massachusetts replaced him with a
    Republican named Scott Brown. Even more extraordinary, Brown was elected
    based on his campaign promise to vote against the health care act. This
    put the house in a delicate position. If they changed even one word of
    the bill then they would have to send it back to the Senate to reconcile
    their version with the original Senate version. If the bill went back
    to the Senate then it was guaranteed to die because the Democrats had
    lost their 60 vote majority. That means that the Senate drafted a bill
    that, according to Chief Justice Roberts, contained a new tax. That’s
    contrary to the Constitution.

    But wait a minute…

    Now a District Appeals Court judge has determined that the law is, in
    fact, not really a tax. Why? Because “the provision’s revenue-raising
    function is incidental to its

    primary purpose”. What? The only way the penalty is Constitutional is if
    it’s a tax, but apparently this judge thinks it’s not important enough
    to qualify as a tax. The only way the Supreme Court could uphold this
    decision is if Judge Roberts reverses himself, in which case the penalty
    isn’t Constitutional and has to be repealed

  • Sue Hawes

    Ah yes, efficiency. Ever since the MBA’s got into the game things have changed. Your care is measured by ‘units’ or measures plus some add ons that have nothing to do with your health situation. I just heard from a cousin, a long time attorney at a prestigious law firm that is now, as he said, is a ‘bean counter.’ It is not the client but the amount of money that can be raked in with clients. Relationship? Outcomes? No

    $$$ Yes