Lessons from the US Health Reform that’s Already Failing

It’s not often I bother reading the numerous articles I come across everyday on US health system reform. But Atul Gawande is a man of clear thought and once again proved he understands health – though I don’t agree with him entirely.

In this article he highlights the failure of recent Democrat reforms to address rising costs and quality in health. He then goes on to say that government intervention can lower costs and improve quality just as happened in agriculture in the early 1900’s.

His argument is intriguing for a number of reasons.

Like many commentators he criticises the free-market approach in health yet fails to realize out that health is not a ‘laissez-faire’ market. Anyone with a basic understanding of markets realizes that there is a fundamental imbalance in health. This McKinsey’s report, for example, explains how most health systems lack a rigorous approach for matching clinician supply with demand for health services. This is despite the clinical workforce using around 60% of the $4bn spent on health each year. In what other industry is there a shortage of 60% of market supply?

The agricultural revolution analogy he uses is obviously a loose one. One cannot compare the complexity of health with the farming system of the early 2oth century. Gawande’s purpose is more to demonstrate that top-down reforms can cause effective change.

You might read his story and swell with sudden belief in the power of the progressive Obama administration to deliver the perfect medicine to our ailing system, from the top down. The success of government intervention in agriculture, however, is one example of top-down success against the myriad of failures well documented in change management science. Indeed, health is perhaps the best example of failure to change with every Democrat president sice Roosevelt having tried and failed.

Top-down reform will be necessary in the interim to accelerate change. But long term I firmly believe that less regulation (without completely removing oversight) is what health requires.

Let me give a small example. In the USA they are looking at a new model of primary care. It’s not unlike the superclinics our Rudd government is building. What strikes me immediately is that they are very much ‘models of the moment’. They are attempts to use existing resources and infrastructure to change health delivery. As Einstein said however, ‘you can’t solve a problem with the same thinking that created it’. Here we are trying to use the same structures, albeit in a re-jigged format, to solve the problem!

Indeed, the Rudd superclinics are already failing: see super clinic an expensive joke.

Health System Dashboards and Quick Wins

It’s been nearly 2 months since my last post. So much has happened since.

Last week I attended a health forum with government and health industry leaders from around Australia. It was both broad and enlightening. My contribution was to promote the need for a consumer focus – along the lines of this recent post. I believe this message was well received by all – except those with entrenched interests such as the medical specialist colleges and health bureaucrats.

At that forum it was predicted that the COAG meeting of 2 weeks ago would achieve no significant reform agreements. Indeed this is what happened – although perhaps with good reason. As Kevon Rudd pointed out, this may need time to get right. The cynics would say we’ve had enough time.

My future goal for this blog is to shift towards promoting simple tools that will provide measurable improvement to our health system. These may be medications, IT or process tools that can be implemented at any level. I will endeavour to give some kind of health economic and regulatory rationale for their implementation. I will also try to outline how these incremental changes can shift healthcare back towards a balanced market.

My first quick win is a health dashboard.

The dashboard is a concept familiar to many in other industries, particularly to business analysts. A dashboard collates and displays information, typically relating to performance. In the case of health, the dashboard could display data for a family health clinic, or indeed for a large hospital or even at the national level.

Healthcare is information rich but data poor. The fact that few of our established pieces of health infrastructure use dashboards demonstrates this. I am aware that hospitals use them in some capacity – but only a limited number of staff have access to them. I know that some GP clinics, particularly those run by corporate groups, have software that can extract this type of data – albeit in a limited format such as a summary of Hb1Ac levels for all your diabetic patients.

Healthcare must move from a reactive art towards a predictive model. A great example of this are radiology dashboards in Baltimore. The idea is to provide data for decision support. Only with overview displays can staff quickly foresee changes and gaps that need to be filled.

In Australia dashboards could be easily applied at the primary care, aged care and hospital level. Most of these facilities already have databases with the relevant information. But doctors have few clues about how to make use of this data. We concentrate of the traditional tools of EBM, diagnosis and management while easily losing sight of the bigger picture.

While policy makers get excited about performance incentives, they need to first consider a far more simple measure of providing overview.

Point-of-Care Testing – A Quick Win Damned by EBM

The decision by our Department of Health not to fund point-of-care testing is a perfect example of how healthcare is stunted by regulation and our concern for evidence in a world evolving faster than we can think – let alone publish systematic reviews.

Point-of-care (PoC) laboratory testing has numerous advantages over the traditional large-scale laboratory systems. The obvious ones  are timeliness and accessibility. According to numerous studies it is cost-effective, and most of those were extremely limited studies that only assessed the actual cost’s of testing – not time saved or travel saved etc. In effect, they were completely distorted studies in terms of cost-effectiveness.

In Australia, where GP’s in remote areas often have to wait 3 days for an INR before adjusting a Warfarin dose, it seems illogical that we can’t give themPoC testing.

It’s detractors suggest GP’s might over-test (as if that doesn’t happen already). I would suggest that the very demands of organising the test in-house, while quick and easy, is still harder than ticking a box and would give GP’s and patients a better sense of the usefulness of their tests.

The last time PoC testing was evaluated by the government was apparently 1997. If they wait another 12 years before the next review I predict we’ll have the ability to buy kits off the internet for home use by then. Only because the government will pay for us to have a doctor do will patients not test themselves.

Yet again, the limitations of bureaucracy and the limitations of trying to evidence-base breakneck speed and complexity means a loss for consumers of health.