Join the discussion on how we can fix healthcare.

We are forming a new singing group called the Four Anythings. We sing about healthcare and you can join in. Remember the song “Anything you can do I can do better” from Annie Get Your Gun?” (If you don’t know it, search Google – it is worth hearing.)

Anything quick won’t work.
Our rational minds know that if it took 40 years to get where we are, we can’t get out of it in 40 days or 40 months. Yet we heed our emotions and nod our heads shouting Yes! when some aspiring politician or self-styled expert promises to fix healthcare next year.

Anything easy is a hoax.
If fixing healthcare were easy, why haven’t they done it already? So, when someone says Just listen to my lovely sound byte – my easy answer – give me your vote (and your money) and I will fix healthcare for you, this is a hoax. Anything easy won’t work. This person is selling you snake oil and you seem eager to waste your money.

Anything cheap will cost more.
Two things to note: predictability and value.

First, what government program ever cost what they promise? The winning bid for the original space shuttle was $2.9 billion. Cost over-runs were triple the entire bid: in excess of $6 billion. Medicare cost over eight times (>800%) the initial projections.

Second, we pay close attention to what something will “cost” but make little attempt to determine its value. We do not consider the long-term but think only about the next budget cycle. What will something, like healthcare reform, cost over twenty years, including avoided costs? What about the second half of the cost/benefit equation: will we get what we really want? What value will we receive?

The phrase “universal health care” has been bandied about recently as something we all want and something that will “certainly” save money. Some politicians say universal health care when they actually mean health insurance. The fact is we want neither. What we all want is to be and to stay healthy. That is not the same as universal health care or insurance, and it won’t come cheap.

Anything simple is for simple problems.
Healthcare has many complex issues, difficult but fixable problems, and is definitely not simple. Why would we ever think that a simple answer, a sound byte of 20 seconds or less, a grandiose and euphonious promise, could solve anything? Ridiculous, yet that is what we are offered and that is what we seem to be buying: simple, easy, “cheap” answers for highly complex problems.

System MD

PS. The Four Anythings can sing at all sorts of parties, not just one for healthcare. We are just as good at family issues, business meetings, and scientific sessions.

This is not a silly or trivial question. Practicing medicine without a license is dangerous, costly and illegal. Yet people do it thousands of time every day without getting caught

Yesterday at our clinical conference, the big problem was Baby X. We had done our research and found an out of state Hospital (A) had the highest success rate (98%) with the heart procedure that the baby needed. The insurance company refused to authorize payment to Hospital A and was demanding that Baby X go to Hospital B. The Medical Director of the insurance company said that Hospital B had an excellent success rate (91%) and was considerably cheaper. They planned to schedule surgery for Baby X at Hospital B.

What if our baby is one of the seven – 98 minus 91 – who die at Hospital B but would have survived at Hospital A? Who is responsible? Who is accountable? What will the family think? Should they sue and if so, whom? Who is practicing medicine (and doing it badly)?

HIPAA (Health Insurance Portability and Accountability Act) was passed by Congress and implemented by several regulatory agencies. It makes it difficult to share medical information. Coupled with the medical malpractice litigation statutes interpreted by each Hospital Counsel, wide dissemination of medical information, especially about adverse outcomes, is virtually impossible. But isn’t that the way we learn how to avoid mistakes? So, mistakes continue – patients suffer, and whose fault is that? Who is practicing medicine here, and doing it badly?

Examples are endless. The fact is that medicine is a complex team sport. Financial, managerial, legal, and operational decisions impact patient outcomes at least as much as strictly medical decisions but only those with MD after their names are held responsible.

How many people practice medicine without a license?
What should you do about it?

System MD

Of course you want the best car or job or school or doctor, but how do you know which is the best? Word-of-mouth? Name or logo recognition? Most expensive? An objective measure is clearly better: resale value of the car; how much the job pays; test scores at the school; and for a doctor…what?

To determine the best doctor, you could look someone up: at the Better Business Bureau; online; in magazines touting the Best Doctors in Chicago or Seattle or New York; or in books such as Who’s Who in Medicine or the Best Doctors in America.

Let me assure you, these have nothing to do with quality. I am listed in most and never, absolutely never, has anyone ever asked for my results with patients. You get on these “Best Doctors” lists by having an impressive title, being at a prestigious institution, or writing lots of papers. These provide a Q-factor. Does notoriety equal quality?

Increasingly, you can get quantitative data but beware! There are four BIG problems interpreting the available data on physician performance and patient outcomes.

(1) The only medical data routinely tracked are outcomes patients do NOT want: deaths, complications, adverse impacts and lawsuits. They do not collect information on the outcomes we DO want like restored function; productivity; longevity; and good health.
(2) The medical data is very user-unfriendly. There is too much of it. The organization is confusing. The labels are incomprehensible: blepharoptosis, laparascopic cholecystectomy, gastrorraphy, and Fontan operation.
(3) The public believes that doctors who get sued are like people who are arrested: probably guilty of something. A lawsuit is thereby used as an indicator of a Bad Apple. However, there is abundant scientific data proving there is NO relationship between lawsuits and quality of medicine practiced.
(4) Most important, medical data are not risk-adjusted. Comparing some one who operates on morbidly obese patients (over 400 pounds) with someone who operates on low-risk patients is unfair. Same idea applies if comparing doctors who work with a drug-addicted east LA population with those who practice in Beverly Hills (well, okay, they may be into drugs too but are more likely to do what their high-priced doctor recommends).

So how do you determine the best doctor? The answer is to demand information that is readily comprehensible to you; that compares apples to apples (not apples to hand grenades); is long-term; and most important, shows outcomes you want not the ones you want to avoid. If your orthopedic surgeon recommends a knee replacement, you want to know success rates – restoration of pain-free mobility; for how long; in how many; how long in hospital; compared to other facilities; etc. – not just hearing that 99% survived and no one has ever complained.

Finally, talking about the “best” doctor implies that this is a competition. It isn’t or shouldn’t be. You don’t want the best doctor – you want the doctor who will do the best for you. There can be many of those.

To determine the best doctor for you, you need understandable (by you) data on long-term, positive, comparable risk-adjusted outcomes.

System MD

Healthcare puts you at risk: there are infinite opportunities for mistakes that can harm even kill you while you are awaiting the promised cure.

The problem really struck home to me yesterday while receiving sign-out – transfer of the responsibility for the patients – from one of my colleagues.

• The patient who was given the right medication but by vein rather than orally.

• The one with a cardiac pacemaker scheduled for an MRI (that would have damaged the pacer) stopped at the last minute because of an accidentally overheard conversation.

• The “routine” catheterization that became a nightmare because there was no place to put the catheter.

• A constantly crying baby whom the nurse tried to console with a binky, not knowing the child was in pain from jaw surgery.

None was seriously injured by these “mishaps,” but they could have been. None was as dramatic of the death of a British cancer patient immortalized in the London Times (2001) or the $10 million lawsuit over the Pennsylvania baby who died from a ten times overdose of heart medication digoxin. Each error was preventable or avoidable. There was no safety system.

A recent push by the Commission that governs hospital accreditation is for a “Culture of Safety.” They mean well but they miss the fundamental point. Most medical mistakes are due to either: (1) Lack of knowledge by medical science, and/or (2) Mistakes made by humans because humans are not perfect.

(1) You cannot legislate new knowledge. That comes only in a learning environment, which we do not have but desperately need.

(2) You cannot legislate human perfection. Nurses and doctors will make mistakes because they are human and [here is the key point] those mistakes will hurt you because there is no safety system to stop them before they happen. The pilot of an airplane literally cannot raise the plane’s wheels while it is on the ground. The system won’t let him.

In healthcare, there are too many people involved. Too many pieces of information. Too many handoffs or sign-outs. Communication is ineffective, and is constrained rather than enhanced. The exploding number of drugs increases the chance of a bad interaction or a wrong dosing. The expanding number of procedures increases the probability of judgment or technical error. The morass of rules and regulations – the incredible complexity – increases chance of a mistake.

Think about your care. Who is more likely to give you safer and better care: a consistent, single “non-expert” generalist doctor, or a number of constantly changing specialist experts writing orders at the same time? I hope that was a rhetorical question. The way medicine is currently structured, none of us has the safer option.

We cannot depend on people being perfect, and “culture” (as in Culture of Safety) means people. We need a System for Safety. Such a system would flash a big red warning DANGER sign when someone tries to: schedule an MRI in a patient with a heart pacemaker; schedule a routine surgery in a child with a congenital airway problem; give the wrong drug or the wrong dosage of the right drug (remember Dennis Quaid’s twins?) to a patient; give two drugs that are incompatible or to which the patient is allergic; operate on the wrong coronary artery (ask Dana Carvey, the comedian); etc, etc, etc.

A “Culture of Safety” won’t keep us safe.
We need a System for Safety.

System MD

We all need to be systems thinkers. Many are, but not bureaucrats and regulators in Washington and in State capitals. You may call them systems Stinkers.

Systems Stinkers think in straight lines. They see a problem; reason their way to an answer without evidence that it will work; and implement their so-called solution. Then they are done, or so they think. Their straight-line thinking usually produces “fixes that fail,” and we pay for their failures.

Systems stinkers do not follow-up on their decisions. They order, someone implements, we pay, and they walk away. They do not consider unintended outcomes. There is no feedback to them, certainly none with effect. If you or I make a bad decision, we get the feedback (“request for payment”) and we have to pay the bill. Systems Stinkers do not. The original space shuttle cost more than 380% over budget. The cost of Medicare was 800% over what was planned. Who paid and is still paying?

Systems thinkers see loops rather than straight lines. They understand that their actions can come back and bite them in the rear. They develop evidence before they act. Their systems have feedback built in. They consider unintended consequences and plan for them.

Nice theory you say but what does it mean in the real world? UMRA and HIPAA are two so-called solutions created by our friendly systems Stinkers.

UMRA (Unfunded Mandates Reform Act of 1998) was Congress’ solution to the problem of medical care that they required [mandated] for which they allocated no money. It was like passing a law requiring gas stations to fill you up with no one paying. How long could gas stations stay in business? UMRA was a fix that failed. There is still no money for mandated care and no consequence to Congress for ignoring their own rules. Systems Stinking in the real world.

HIPAA the hippo is a new low. Originally intended to protect us from losing our health insurance, HIPAA is now supposed to secure our medical privacy, but doesn’t. It costs hundreds of millions of dollars, and the only thing it produces is medical errors. The systems Stinkers’ solution made things worse.

Systems thinking has loops not lines; evidence before action; plans for various contingencies; and proper feedback. Systems thinking would have fixed unfunded mandates as well as insurance portability, in contrast to UMRA and HIPAA.

Systems Stinkers need to become systems thinkers.
Otherwise, we will all drown in red ink and dead bodies.

System MD