Atul Gawande is a Boston area physician who writes extensively about healthcare. His latest article will appear in the upcoming issue of the New Yorker magazine. I found the article to hold some amazing insight about the future of healthcare. It is a long article, but well worth the time. Here is the link to the full article: Big Med (The New Yorker)
The author opens with an explanation of how the Cheesecake Factory is able to bring high quality food at reasonable prices to a mass audience. The chain is wildly popular and the food is quite good. Through a combination of standardization and relentless quality control, they are able to take complicated recipes and reduce the variation dramatically. The result is a perfect wasabi-crusted ahi at any one of their restaurants all for the same moderate price throughout their chain.
He then compares that to our current healthcare system. In his words, we are getting "greasy-spoon fare at four-star prices." Proven medical innovations can take, on average, fifteen years to become the new norm. Expensive treatments that are proven to have little or no clinical value are routinely ordered. He wonders what might happen if healthcare could adopt some of the best practices of the restaurant industry.
To give one example, he cites the fact that controlling food waste is extremely important to a restaurant. The Cheesecake Factory is able to project demand so well that they only throw away about 2.5% of their food (on average)!
He goes on to discuss his mother's experience with a knee-replacement surgery. John Wright, a surgeon at Brigham and Women's, is reshaping the orthopedic department. He is taking best practices and creating new, standardized procedures for joint replacements. He says, "Customization should be five per cent, not ninety-five per cent, of what we do."
Those changes have not been easy for the staff to accept, but the results have been positive:
...He told me that about half of the surgeons appreciate what he’s doing. The other half tolerate it at best. One or two have been outright hostile. But he has persevered, because he’s gratified by the results. The surgeons now use a single manufacturer for seventy-five per cent of their implants, giving the hospital bargaining power that has helped slash its knee-implant costs by half. And the start-to-finish standardization has led to vastly better outcomes. The distance patients can walk two days after surgery has increased from fifty-three to eighty-five feet. Nine out of ten could stand, walk, and climb at least a few stairs independently by the time of discharge. The amount of narcotic pain medications they required fell by a third. They could also leave the hospital nearly a full day earlier on average (which saved some two thousand dollars per patient).
Gawande then discusses the virtual ICU concept as practiced by the Steward hospital group. There are ten hospitals serving 8,000 patients per year. The centralized command center is not meant to replace the staff on site. They can augment the staff on hand by ensuring that the protocols have been followed and that important warnings are given proper attention.
These changes will bring savings but they will also create a great deal of disruption and uncertainty.
Those of us who work in the health-care chains will have to contend with new protocols and technology rollouts every six months, supervisors and project managers, and detailed metrics on our performance. Patients won’t just look for the best specialist anymore; they’ll look for the best system. Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more. We’ll also have to figure out how to reward people for taking the time and expense to teach the next generations of clinicians. All this will be an enormous upheaval, but it’s long overdue, and many people recognize that. When I asked Christina Monti, the Steward tele-I.C.U. nurse, why she wanted to work in a remote facility tangling with staffers who mostly regarded her with indifference or hostility, she told me, “Because I wanted to be part of the change.”
He closes with an interesting flourish:
The critical question is how soon that sort of quality and cost control will be available to patients everywhere across the country. We’ve let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. The Cheesecake Factory model represents our best prospect for change. Some will see danger in this. Many will see hope. And that’s probably the way it should be.
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