Last year I wrote about work done by Professor Leidy Klotz and colleagues about the value of subtraction. They had just published a paper in Nature and he was about to publish a book (Subtract), which is now about to be released in paperback. Their research found that, on a variety of tasks, people tend to look for changes that involve adding instead of subtracting, even when subtraction produces more efficient/effective solutions.
Playing Jenga. Credit: Elite Learning
I want to return to how this applies – or should apply
– to healthcare.
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Here’s a word that is not often used to describe our
healthcare system: baroque. Not in the
sense of medieval art/architecture, but in the sense that 16th
century philosopher Michel de Montaigne defined
it: “Bizarre and
uselessly complicated.” Yeah,
that’s healthcare.
In his book, Professor Klotz
often talks about Legos. Kids love to
build with them; the more Legos, the better.
Addition is the expected course of action. I like the analogy, but I think healthcare is
more like the new television show Domino
Masters, where players build ever more elaborate, more baroque structures
out of dominos. One domino falling
brings about collapse, usually in spectacular ways.
Credit: Ray Mickshaw/Fox
In the show, the
collapses are carefully engineered to be aesthetically pleasing, but when a domino
in the healthcare system falls, there’s no telling what other pieces it’s going
to bring down. This part of the supply
chain is late, those nurses are burnt out, some social media influencers put
out disinformation, and soon we have our collapses.
If Legos are the
additive analogy, the subtractive analogy Professor Klotz uses is Jenga. In
Jenga, one starts out with a stable structure, and players keep removing pieces
until it collapses. The surprising thing
is how many pieces can be subtracted before that collapse happens. It takes a careful eye and a strategic sense
to recognize what a safe subtraction will be.
Healthcare needs plenty of subtraction, but carefully
and strategically.
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Let’s go through some potential healthcare Jenga moves:
Payors: the U.S. has a ridiculous number of payors. In government programs, for example, there’s not only Medicare and Medicaid, but also CHIP, the VA, CHAMPUS, TRICARE, and the Indian Health Service. The number of private payors is in the tens of thousands, considering that each self-funded employer is its own payor. Even counting just health insurance companies and third party administrators, the number is in the hundreds, if not thousands.
I am not a MedicareForAll person, partly because that term tends to mean something different to each person using it, and am similarly skeptical of the savings/efficiencies “single payor” advocates tout. But there’s no doubt that we’d have a more effective healthcare system if our approach to payors was to start subtracting. Answer: too many. Credit: PolictAdvice
Networks: I hate provider networks. Payors/administrators may claim that networks allow them to exercise more effective oversight of the various providers, to the benefit of consumers, but networks are primarily about price.
We should not be looking to steer people to the
cheapest providers. We shouldn’t even be
steering them to the average cost providers.
We should be helping them get to the providers who are most capable of
helping them the most. Done right, the
best quality care shouldn’t be the most expensive.
If I could wave my magic wand, I’d subtract all
networks in healthcare, and focus on identifying which providers can best help
who with which issues.
Prices: Speaking of
price, legislators and policymakers are patting themselves on the backs for
recent “transparency” accomplishments, which involve making public more of the
negotiated deals between payors and providers. It’s an addition that sounds praiseworthy,
but isn’t really.
For decades, and now moreso than ever (ICD-10,
anyone?), healthcare prices have been so granular as to be meaningless to anyone
not intimately involved in billing. There are just too many codes, with too
many modifiers. Trying to understand in advance
what your cost will be is usually futile…and even understanding your bill once
you get it is often equally baffling.
There are way too many things for which we have prices,
and way too many different prices for those things. Each payor has its own set. For years, Dan Munro has been calling for “Single
Pricing” rather than Single Payor. He
may be right, but one thing is clear: when it comes to healthcare prices, we
should be subtracting – fewer levels of pricing, for fewer things.
Administrative hurdles:
everything in healthcare, it seems, involves filling out forms and
waiting. It doesn’t matter that you’re
already filled out forms and/or waited; you’re going to do more of both. It’s bad enough that we make it so hard for
people to figure what they need, but it’s inexcusable that, even once they do,
we put more barriers before they can get it.
If you’re working in healthcare, every time you ask a
patient to do something, ask yourself: is this really necessary? Does it improve their health? Or is this a step that could, instead, be
subtracted?
Cost-sharing:
Almost every type of health insurance in the U.S. has some form(s) of cost
sharing, including deductibles, coinsurance, and copays. Advocates claim that cost-sharing deters unnecessary
care, but let’s not kid ourselves; the purpose of cost-sharing is to transfer
costs from healthy people (in their premiums) to people using health
services. Is that who we really are?
For example, as many have pointed out, what’s the point of cost-sharing for insulin? Cost-sharing is just a financial burden on them; they can’t really skip insulin or use less. There are plenty of other examples.
There may be some role for some very targeted cost-sharing,
but the general rule of thumb for it should be subtraction.
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Right now so-called digital health is having an explosion
of venture capital investment in record numbers of health tech companies. Healthcare
certainly needs to be more digital, but thousands of new point solutions is
addition at its worst. Who is funding the companies who subtract from our
healthcare system?
If you are a healthcare innovator, trying to bring
change to the healthcare system, ask yourself: am I adding to our baroque system,
or am I subtracting things that don’t need to be there?
People in healthcare act as though they are afraid that
any subtraction, as in Jenga, might cause the structure to collapse. What they
really should be worried about is that they’re adding the domino that causes
the chain reaction of destruction.
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