VentureSwell

If you care about health care, go read this latest piece from Atul Gawande. It's almost unquotably good. He compares our efforts to improve the American health care system with the agricultural reformation that began in the early 20th century, driven by pilot programs and experimentation.

What seemed like a hodgepodge eventually cohered into a whole. The government never took over agriculture, but the government didn’t leave it alone, either. It shaped a feedback loop of experiment and learning and encouragement for farmers across the country. The results were beyond what anyone could have imagined. Productivity went way up, outpacing that of other Western countries. Prices fell by half. By 1930, food absorbed just twenty-four per cent of family spending and twenty per cent of the workforce. Today, food accounts for just eight per cent of household income and two per cent of the labor force. It is produced on no more land than was devoted to it a century ago, and with far greater variety and abundance than ever before in history...

There are, in human affairs, two kinds of problems: those which are amenable to a technical solution and those which are not. Universal health-care coverage belongs to the first category: you can pick one of several possible solutions, pass a bill, and (allowing for some tinkering around the edges) it will happen. Problems of the second kind, by contrast, are never solved, exactly; they are managed. Reforming the agricultural system so that it serves the country’s needs has been a process, involving millions of farmers pursuing their individual interests. This could not happen by fiat. There was no one-time fix. The same goes for reforming the health-care system so that it serves the country’s needs. No nation has escaped the cost problem: the expenditure curves have outpaced inflation around the world. Nobody has found a master switch that you can flip to make the problem go away. If we want to start solving it, we first need to recognize that there is no technical solution.

Our most challenging long-term health care goals - reduction in costs and improvements in quality of care - aren't solely technical challenges that can be solved with a single plan. The path to "fixing" health care, then, is just that: a process rather than operation. It requires investigation, experimentation, and measurement across a disparate array of social and regulatory contexts. We can effect institutional change across a landscape this fragmented by prototyping extensively and seeing what works best; we need a portfolio of innovation. This is exactly the approach the current Senate bill takes, as Gawande notes: "it contains a test of almost every approach that leading health-care experts have suggested...None of this is as satisfying as a master plan. But there can’t be a master plan."

This is how we build new companies and products, and it's refreshing to hear it being applied by government. It's also awesome to see another analysis of this caliber by Gawande. He's established himself as likely the best health care journalist we have.

Good piece in the Technology Review about resistance to implementing electronic medial records by the medical industry. His main points call out the fundamental misalignment of incentives, which reward treatment volume rather than quality of care or prevention:

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That's an f*ing large number. A fairly new angle for me was his call that EMRs will enable data mining & analysis and longitudinal studies on a scale still impossible today. It's a pretty fascinating and hopefully important idea, though there's no discussion of the new data silos that will result or the coming fights over privacy, ownership of patient data, and access to that data.

And, finally, a point that doesn't come up until the comments - it's hard to get patient data into EMRs in the first place. Doctors aren't used to it and most of them don't want to learn. Changing human behavior is hard, and the massive friction added to the exchange by deeply shitty user interfaces. It's going to take careful human-centered design not just of the EMR software itself, but of the hardware interfaces and, particularly, the organizational behavior and processes that surround it - the people matter.

via Jay Parkinson + MD + MPH. If you're interested in health care you should read his stuff.

Draft.

Atul Gawande has another fascinating piece in the New Yorker about the challenges facing the broken American health care system. He looks to McAllen, TX - one of the nation's most expensive health care markets, where Medicare spends almost twice the national average per enrollee (which also happens to be greater than the per capita GDP) - to find some answers.

Do patients in McAllen get better care for all that extra cost? No. Research shows, in fact, that per patient Medicare costs and quality of care are negatively correlated on a State-by-State basis.  The long and short of it is that there is an overwhelming tendency for doctors in McAllen to treat their patients as revenue sources, first; the quality of their care is a lower priority.

Are these folks assholes? Absolutely. But wherever you find shared behavioral patterns, no matter how noble or diabolical, you can bet that there are structural and institutional drivers. So what drives the behavior of those McAllen docs? Well, they get paid for it. They perform many more high cost diagnostic and surgical procedures per patient with no associated increase in patient health. The American health care system bases provider (re)compensation on volume rather than quality of care.

In this context, the "public vs. private" health care debate starts to take on a different shade. Gawande notes:

He contrasts the example of McAllen with some of the success stories: hospitals (or hospital systems) like the Mayo Clinics and Kaiser Permanente, and more loosely affiliated "accountable-care" organizations (read the article). The success of these arrangements - high quality of care and low per patient costs - seems to be driven by a few interrelated factors: a focus on patient care quality as the bottom line, enabling and empowering (or even requiring) collaboration among docs, paying salaries rather than procedure-dependent physician reimbursement, and non-profit health care organizations.

Shocker: to get quality health care, make sure your structural incentives are properly aligned.

Rather than focusing on patient care, most of the US health care system is instead driven by a perverse compensation system in which neither doctors nor hospitals are rewarded for keeping patients health. Yeah, they both make more when their patients are sick. What do you expect will happen?

To be clear: I don't lay blame at the doctors feet. My grandfather was a doctor, and my dad, sister, brother and sister-in-law are all docs today (two surgical oncologists, pulmonary intensive care specialist, anesthesiologist and OB-GYN, respectively). They are all deeply and truly good people, and they - like many and perhaps most others - do amazing work as physicians and human beings. That being said, do we want to put our trust in the nobility of a few individuals against the weight of the $2 trillion health care industry?

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From my perspective, the main point of failure of American health care is the decoupling of health care providers, insurers, and the value of healthy people. Health care providers - both hospitals and physicians - should be paid to keep people healthy. Instead, they're reimbursed based on patient & procedure quantity. Shouldn't insurers have a vested interest in having health (low cost) customers? You'd think, but several factors undermine most hope for that: their ability to constantly re-arbitrage and refuse to insure high-risk individuals, high customer churn (cough terrible customer experience), and their demonstrated lack of ability to innovate and address the long term.

That's the heart of it - the greatest part of the value of health care is in keeping people healthy. The value in preventive care, though, is realized in the long term through dramatically reduced health care costs. No one has figured out how - or has had the balls to try - to capture this value yet.

Our health care mess feels a lot like the initial lending abstractions that contributed to the current financial crisis. Banks used to lend known families and individuals money to buy a home; because they held that risk themselves, the financial health of their customers and that relationship itself were of great importance. Once banks started selling their mortgages to Wall Street, they became brokers.

Doctors and hospitals should not be brokers of health care services, but that's what the US health care system has made them. Until we address the underlying incentive structure, we're largely fucked. As Gawande put it: