Friday, May 30, 2014

Mistaking Failure for Success

It would be easy to think of hospitals as the crown jewels of our health care system.  After all, they are the largest single component of health care spending, accounting for almost $1 trillion of our $3 trillion total.  They've outspent and outmaneuvered all the other players in vertical and horizontal consolidation.  And everywhere I go I see scaffolds up near hospitals, as they keep building additions and renovating existing facilities

Let's face it: hospitals are -- implausible as it may sound -- sexy.  You see a lot more television shows set in hospitals than you do set in, say, doctors' office or pharmacies (and certainly none are set in health plans!).  Local news programs love to feature the local hospital's latest piece of (expensive) technology.  They get the best, most expensive new technologies (although they aren't always so good about getting rid of older ones).  According to The New York Times, hospitals now pay their CEOs like rock stars -- making even more than surgeons.

Instead of seeing hospitals as our crown jewels, though, perhaps we should look at them as symbols of our failures.

Think about how we measure hospital performance: how many patients die or get an infection during their stay, or are readmitted soon after they leave.  Those are all measures of failure, not success.  Would Toyota compete on the basis that fewer of their cars catch on fire, or would Apple brag that only a third of their customers return their iPhones?

I don't think so.

Contrary to how hospitals measure it now, success isn't discharging a patient alive; success is keeping people from needing to be admitted in the first place. 

Oh, sure, we're starting to use patient satisfaction scores (HCAHPS) to measure hospitals but I'm not convinced that either clinicians or administrators view them as much more than part of a "value-based" payment/ penalty. Then, again, hospitals historically haven't liked to be measured at all, aside from their bond rating or stock price.

All this is supposed to change through the advent of value-based purchasing and patient-centered care, but somehow I don't think hospitals are going to change without a fight. 

I enjoy reading articles about futuristic hospitals and hospital rooms, like those envisioned by Kaiser Permante, Patient Room 2020 or Swisslog.   The buildings tend to look like luxury hotels, with snazzy yet welcoming decor and furnishings.  The rooms are upscale as well, with high-tech yet comfortable beds, wireless monitoring, and rich patient entertainment options.  Maybe some robots.  It's all very exciting, but I can't help but thinking all this redesign is going to make our already too-expensive hospitals even more expensive.

Health care futurist Joe Flowers recently wrote a great piece about tech in health care that I think applies well here.  Everyone seems to agree that there is too much waste in health care, but Flowers notes that: "we have so much waste because we get paid for it."  Even more than that:
In an insurance-supported, fee-for-service system, we don't get paid to solve problems. We get paid to do stuff that might solve a problem. The more stuff we do, and the more complex the stuff we do, the more impressive the machines we use, the more we get paid.
Nowhere does that apply more than in hospitals.
What I would like to see is for a health system to do sort of a mortality and morbidity review committee on steroids.  I'd have them go through every patient, every admission, and do a deep dive on why the patient ended up in the hospital -- and what could have been done to avoid it.  That doesn't mean just the most immediate cause, but tracking each patient's health problem(s) way upstream to determine what, if any, earlier interventions could have avoided the need for an admission.

It's like zero-based budgeting for admissions. 

Instead of investing in further new, expensive technologies in the hospital, I'd then want the hospital invest in the infrastructure that would have prevented those admissions, or most of them.  We should declare a halt to the hospital facilities arms race, or at least change it to one funding outpatient/at-home solutions.  Hospitals should have the mindset that, instead of reaping lots of money for each admission, they owe someone -- maybe even the patient -- money if a patient ends up in a hospital bed.

That would get administrators' attention real fast.

Some quick examples of the kinds of things that can allow admissions to be avoided:
  • The FDA just approved a blood pressure monitor that allows remote monitoring of patients with congestive heart failure.  Its maker, CardioMEMS, thinks it could benefit as many as a million patients a year.  It is expensive to implant, but would pay for itself by avoiding a single admission.  
  • The ClearCell® FX System from Clearbridge BioMedics that can track circulating tumor cells from blood tests, allowing much more real-time monitoring of the progression of cancers and avoiding more invasive and expensive tests.
  • Samsung beat Apple to the punch by unveiling their digital health products that focus on health tracking through a variety of health trackers and a "data broker" for all the data generated.
  • Even stodgy Intel is getting in the game, announcing their "smart wearable shirt" to track vitals associated with exercise.  Intel expects it to be the first of many.wearable monitors. 
I won't belabor the point, but the folks at MobiHealthNews just did an in-depth discussion of how patient-generated care is going to change not just how, when and where care is delivered, but how we think about care.  It is a brave new world, and hospitals are old school.

I just worry that the cost of all these new technologies end up being additive, as we tend to do in health care (see MIT researcher Jonathon Skinner's fine analysis The Costly Paradox of Health-Care Technology).  If we have all these big hospitals with lots of patient beds waiting to be filled and lots of expensive equipment waiting to be used, there's still going to be pressure to use them.  Hospitals are not buying all those physician practices just because they like doctors.

Dr. Kenneth Davis, the CEO and President of Mt. Sinai Health System, recently wrote that what we think of as hospitals have to become integrated delivery systems, featuring pro-active, community-based care and focused on population health management.  As he says, "instead of measuring hospitals by the number of beds filled with patients being treated for illnesses, the hospital of tomorrow will be judged more by its ability to maintain a community’s health."

Or as health architect Robin Guenther told the Pittsburgh Post-Gazette, "the days of hospitals being seen as islands of disease in an otherwise healthy city are over." 


Certainly there will always be some patients who need the intensive care and services only hospitals currently provide, but I'll bet that number can -- and should -- be a lot less than it is now.  I think that only comes when we start accepting that we've failed (most) patients if their health gets to the point they need to go to a hospital.  

It's not just hospitals, of course.  Physicians and other health care professionals have to move away from a mindset of treating unhealthy people -- usually with some sort of acute incident or concern -- to truly managing the health of the people in the community.

One sign of success may be when we stop using the term "patients," with its connotations of illness and of literally being patient for whatever health care professionals decide to do to them.  Shouldn't we just think of them as people?

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