Healthcare beyond Reform: Doing It Right for Half the Cost
(Productivity Press, 2012)
Otis Webb Brawley, M.D., with Paul Goldberg
How We Do Harm: A Doctor Breaks Ranks about Being Sick in America
(St. Martin’s Press, 2012)
Pursuing the Triple Aim: Seven Innovators Show the Way to Better
Care, Better Health, and Lower Costs
Although it reflects an industry on the brink of deep and shuddering structural change, the healthcare bookshelf offered surprisingly few big, new ideas this year. Perhaps this is due to the damming up of ideas and initiatives behind the ongoing battle over healthcare reform in the United States. The Supreme Court’s decision to uphold the Affordable Care Act (ACA) in June 2012 should have released lots of pent-up energy, but, in a presidential election year rife with calls for repeal and a political atmosphere more akin to sectarian violence than civil discourse, uncertainty still hangs in the air.
Somewhat ironically, this year’s healthcare books are focused mainly on the provider sector of the industry, even though the more revolutionary aspects of the ACA — mandatory coverage, state-run insurance exchanges, and the banning of some extremely unpopular practices, such as annual and lifelong limits and denials for preexisting conditions — are aimed at the payor sector. This may be a function of the size of the audience: A few big insurance companies will drive reform on the payor side, whereas reform in care delivery will involve many providers, including more than 5,000 hospitals and 850,000 licensed doctors in the U.S. — a much larger potential readership.
In one way or another, most of the books dealing with healthcare this year are about the ACA. Naturally, many of them either are loaded with ideological and political rhetoric or are simply jeremiads — long on now-familiar indictments of the healthcare system, but short on useful insight. The fact that the system is fundamentally flawed stopped being news at least 10 years ago. What are we going to do about it?
Happily, there are a few insightful books that address this question, which is of interest to us all. Executives in all industries are dealing with the unsustainable rise in healthcare insurance and benefits costs and, of course, everyone deals with the healthcare system on a personal level. Each of this year’s best business books examines the vital issues in healthcare, offers ideas well within the grasp of educated citizens, and makes a meaningful contribution toward a better future.
The $100 Billion Question
Healthcare beyond Reform: Doing It Right for Half the Cost, by Joe Flower, a veteran journalist who has written for strategy+business on several occasions, is the most well-organized, comprehensive, and sensible “big picture” book about improving care delivery this year. It belongs on the shelves of leaders and thinkers within the industry, and is still sufficiently jargon-free to appeal to a broader audience. What sets the book apart is its powerful framework for sorting out what’s most important in the quest to provide higher-quality care to more people at lower cost, some commonsense metrics that keep our eyes on the prize, and a blame-free approach to causality that is refreshing. Oh yes, and Flower’s priorities and recommendations are persuasive.
Flower borrows a proven framework from operational strategy and adapts it to focus on three levels of care delivery improvement: avoidance (do we really need to do this?), coordination (do the components function effectively?), and efficiency (are we working smart and fast enough?). He uses this framework to identify the points of greatest leverage in the attack on healthcare’s problems by defining major cost and performance drivers and, at a high level, quantifying the opportunities. Of even greater usefulness is his characterization of the improvements and savings available from each of these three levers. Flower uses a stubby-crayon methodology here — his “savings scale” is calibrated from “gobs” and “vast sums” to “fascinating amounts” and “interesting amounts.” Unsurprisingly, the biggest opportunities reside at the avoidance level.
Eventually, Flower does estimate the actual financial impact of specific initiatives, while repeatedly using a single metric for significance — the estimated US$100 billion needed to extend healthcare coverage to people in the U.S. who are uninsured today. Any strategy or program that has the potential to make a significant dent in that number through savings and reinvestment jumps to the top of his priorities for action.
Amid this year’s bumper crop of healthcare books, Flower has a thesis that is more causally straightforward and far less high-and-mighty than most. He has two rules for understanding economic behavior: (1) “People do what you pay them to do,” and (2) “People do exactly what you pay them to do.” So, while acknowledging the usual list of unintended and undesirable consequences in the U.S. business model for healthcare, Flower spares us the unproductive indictment and prosecution of the usual suspects (such as greedy doctors, heartless insurance companies, and overpaid executives).
Instead, Flower puts the emphasis in the right places. The biggest savings, he concludes, will come from addressing “inappropriate therapies; ‘heroic’ end-of-life treatment; pharmaceutical waste; [and] the acute results of untreated, preventable chronic disease.” Making major strides in these areas won’t be easy, but he sees the ACA as having many of the structural and financial features needed to move forward. For instance, everyone needs to have coverage, not just to spread the actuarial risk across entire lifetimes, but to enable access to the right level and type of services. The ACA gives the previously uninsured an alternative to the hospital emergency room, which is a terrible, and terribly expensive, setting for primary care.
The major thrust of the book’s delivery-side prescription can be summarized as an endorsement of intensive, targeted, and proactive primary care under the umbrella of a close-knit provider system whose members’ pay is based on health status and results, not volume and transactions. Flower cites research showing that some of the oldest and most respected health systems, including the Mayo Clinic, Cleveland Clinic, and Kaiser-Permanente, have used this approach with outstanding results and demonstrably lower cost per covered patient.
Can the U.S. healthcare system cut its costs by 50 percent, as suggested in the title? Probably not, but 20 percent looks achievable. The book’s framework and recommended priorities for action are the most attractive options available, and the good news, as Flower points out, is that many leading organizations are moving dramatically in the right direction. For these reasons, I commend Healthcare beyond Reform as the best healthcare business book of the year.
Evidence-based medicine and the standardization of treatment protocols are pillars of both the ACA and Flower’s recommended approach. Although there is a lot to be gained by vetting and standardizing fairly noncontroversial screenings, interventions, and treatments, it is a complex and nuanced subject. None of this year’s books on healthcare speak to the subject as eloquently and engagingly as Otis Webb Brawley’s How We Do Harm: A Doctor Breaks Ranks about Being Sick in America.
The title suggests a tell-all memoir, but the top clinician and executive at the American Cancer Society gives us much more. Brawley, who is also an oncologist and professor at Emory University, relates his inspiring personal journey — from poverty in Detroit to his life as a prominent scientist, physician, and leader — using sometimes moving, sometimes disturbing, and often cautionary and self-questioning stories from his career and patients. Each story not only illustrates structural and moral failures in the healthcare system (without preachiness), but also digs into the science underlying some of the thorniest issues in medicine and healthcare.
Brawley is well aware of the need for evidence-based medicine and standardization. But he also points out the sometimes shaky science underlying the current standards for screening and treatment. To screen or not to screen? To treat or not to treat? These questions are not easy to answer; they go to the heart of arguments about rationality versus rationing, value versus cost, and population health versus individual health.
These profound issues are regularly in the news, but they are seldom examined in greater depth than headline teasers. Worse, they are often misrepresented, politicized, and trivialized by terms such as “death panels” (which do not exist) and “government rationing.”
Brawley frames several of them as issues of denominators versus numerators. Consider annual mammograms for breast cancer screening. For women between 40 and 49 years of age, only a few tumors per thousand screenings will be found, and the mortality rate will not be significantly affected by their early discovery (earlier, say, than those found through digital exams). The cost of the screenings, plus the cost (and anguish) of pursuing large numbers of false positives, dwarfs the benefits of affecting mortality in a small number of cases. If you make health policy or pay the bills for lots of plan members, the decision appears obvious: Cut the screenings. If, however, you are a woman who is not just in the denominator (population) of this analysis, but also in the numerator (i.e., you have a tumor), the decision is not easy at all. In fact, for too many patients, the only question may be, “Do you feel lucky?”
For gender balance, Brawley presents a similar example involving prostate cancer screening and treatment, which are actually somewhat more complex because of one simple fact: Far more men have prostate cancer when they die (28 percent) than die from prostate cancer (3 percent). Which cases merit intervention? Do screenings that result in treatment interventions actually cause more harm and expense than good? Research aimed at answering these questions is under way, but it is unlikely to remove the uncertainty anytime soon. Meanwhile, Brawley points out, the push for prostate cancer screening is not altogether altruistic: Depends and Viagra, both of which enjoy strong demand from those men suffering from the complications of often unjustified treatments, are among the sponsors of free (or deeply discounted) community screening programs.
Other than the dogged pursuit of rigorous research and honesty with the public and patients, Brawley doesn’t offer answers to these dilemmas. But he does take a strong stand on the need to personalize the issues as much as possible — a refreshing and attractive characteristic in a physician with academic and research interests. And he tells us what good research science is and what it is not (with compelling examples from his early-career work at the National Cancer Institute).
How We Do Harm is a profound and moving deep dive into the sociology and ethical challenges of healthcare and medicine. It is also a very accessible tale of caution and offers wisdom about the limitations of evidence-based medicine in a world with insufficient evidence.
Profiles in Excellence
Pursuing the Triple Aim: Seven Innovators Show the Way to Better Care, Better Health, and Lower Costs delivers just what the title promises. Its authors, Maureen Bisognano, president and CEO of the Institute for Healthcare Improvement, and Charles Kenney, an award-winning author and former journalist at the Boston Globe, take some of the big ideas discussed by Flower and Brawley and show how they have been put into action. Each chapter features a different case study, and the seven cases in the book illustrate how new approaches can powerfully change care, outcomes, and costs for the better.
Although the chronological format of the cases is sometimes too linear and overly detailed, Pursuing the Triple Aim ultimately succeeds. The issues and opportunities tackled in the book are diverse, and many echo the high-impact hierarchy suggested in Flower’s book. The cases include diabetes management for patients of an HMO, improvement of costs and outcomes for a state Medicaid population, experiments in moving away from fee-based medicine, and the reengineering and reimagining of end-to-end care for high-cost but high-volume procedures such as joint replacements.
For healthcare executives charged with tackling care improvement, the here-and-now, been-there-done-that tone should be motivational. The deck is a bit stacked because almost all of the cases are drawn from highly integrated provider systems (doctors and hospitals operating under one organizational umbrella) with a history of being paid via some kind of set fee per member, as opposed to the traditional fee-for-service model. This will make it somewhat harder for less-integrated provider systems to mimic the scenarios in the book, but it shouldn’t be a major drawback because virtually all healthcare delivery systems have been moving toward greater integration of physicians and hospitals over the last decade.
Perhaps the most compelling case, involving the Virginia Mason Medical Center in Seattle and Intel Corporation, illustrates the potential of major employers working with their biggest healthcare “suppliers” to control costs and improve care. Building on a small-scale effort aimed at reducing costs and absenteeism due to minor lower-back pain among Starbucks employees, Virginia Mason and Intel, both experienced and committed lean organizations, used two simple questions to create the foundation for a new delivery system for back patients. Virginia Mason asked, “What do our customers want?” and Intel asked, “Why don’t we buy healthcare as rationally as we source everything else we need?” Their goals for back pain patients were ambitious: They wanted complete patient satisfaction, same-day access, rapid return to function, and 100 percent use of evidence-based medicine in every case.
The journey taken together by Virginia Mason and Intel to achieve these goals was complex, and it involved more and more players as it evolved, including multiple markets, new providers, and insurers. It has a happy ending, of course, and the process used can be replicated to improve systems and treatments for other high-volume conditions, such as depression, diabetes, and abdominal pain.
The authors share analytical techniques, organizational approaches, metrics, and inspirational vignettes in each of the case studies. But these studies are first and foremost lessons in the need to focus on goals rather than tools. Other how-to books generally shoot too low — imparting skills, but too often aiming at minor targets. Pursuing the Triple Aim shoots higher and hits its mark.
There will be a lot of “gee-whiz” advances in the science and technology of healthcare in the coming decades. But as wonderful as that future promises to be, we will never see its true value if we don’t address the structural, moral, and operational challenges burdening our current healthcare system. Each of this year’s best business books on healthcare is a real contribution toward making that better future more likely.
- J. Philip Lathrop is a senior executive advisor with Booz & Company, specializing in the improvement of healthcare delivery, and the author of Restructuring Health Care: The Patient-Focused Paradigm (Jossey-Bass, 1993).