Patients don’t understand what “low value care” really means

…and can you really blame them?  I mean, after all, it’s REALLY tough right now for those of us in Medicine to measure “value”.  I wrote about the issue here and it’s a huge problem.  (Some examples of all the definitions of “value in healthcare” are shared here.)

Take a look at the excerpt below, and click the link, for recent survey info that indicates patients don’t fully get that concept of what low value care looks like.

Previously, I described a novel tool to measure healthcare value here…but let me tell you:  whether you like that potential measure or not, right now there’s no commonly accepted way to measure what value looks like in healthcare.

Can you blame patients for not understanding what “low value” care looks like if we, in the healthcare game, can’t get together on how exactly to measure value?  Nope, probably not.

The researchers found that two-thirds of those surveyed “had some sense of what low-value care might entail, though many were uncertain about the specifics.” Additionally:Many who offered a description of low-value care saw it in terms of only testing, not treatment.About 5% “anticipated that excessive medical care might harm patients.”About 1% made a link between low-value care and medical costs – either their own or the nation’s.Pages

Source: Low-value Care Misunderstood By Patients | costs, patient experience, value | HealthLeaders Media

Life, Liberty, & The Pursuit of…Healthcare?

By:  David Kashmer (@DavidKashmer)

In America, we long ago declared that people are created with rights.  Among those are Life, Liberty, and the Pursuit of Happiness.  Our famous Declaration of Independence states that those well-known rights are some among others.  If our Declaration were penned today, what contemporary ideas would be enshrined in the document?  Would a modern Declaration list a right to healthcare among our unalienable rights?

 

I share this question, which I’ve asked to more than 223 (and counting) medical students and resident surgeons, to highlight a fundamental issue in America—and I won’t share my own answer.  The point of the exercise here, in fact, is to put forward certain thoughts on the rights we all accept and whether there is another potential right that we don’t seem to have a consensus about as Americans.

 

On one hand, how exactly can we pursue a meaningful life, personal liberty, or our happiness without health?  Does it lurk behind our other unalienable rights as a necessary pre-condition?  If we are unable to be mobile, to experience life, or to pursue our liberty…well, isn’t health and healthcare a necessary pre-requisite “unalienable”?  Would Mr. Jefferson include that in his list if he were to write it today?

 

Yes, asking the question like that, out of historical context, suffers from some real problems.  Mr. Jefferson did not write in modern times and of course the document would be different.  Times are different now as are the related issues.  Healthcare is remarkably different than the field that lead to President Washington’s wooden teeth.  (By the way, in fact that is a myth about George Washington.  His dentures were not made of wood.  Look here.)

 

Anyhow, the issue is not really about whether Mr. Jefferson would include healthcare in a modern rewrite of the Declaration of Independence.  That question is a device used to frame a conversation.  Would we make healthcare a right if we created a list of our key rights today?  If humans have certain rights, and only some inalienable examples are listed in our Declaration but not all of them (remember “among these are Life, Liberty, and the Pursuit of Happiness…) would we list healthcare as another item if we revisited the list?  It is the spirit of the question, and the conversation it creates, which makes me ask many of the healthcare providers with whom I work.

 

Of the 223 I’ve asked, the overwhelming majority have answered that yes, healthcare should be considered a right…but then things get messy.  Conversation usually turns to a related question:  “How much healthcare is a right?” All of it?  Anything we want as patients (even if some type of care won’t do anything to help us pursue life, liberty, or happiness…) despite the healthcare provider’s judgment on efficacy?  Should it be every extraordinary skill we have in modern medicine?

 

The conversation gets complicated, and staff consider with me the various complexities of considering healthcare as a right.  Participants start to wonder what’s worse:  an overly paternalistic physician deciding what’s best for the patient with a devil-may-care-what-the patient-thinks attitude (Dr. House!), or when we as patients demand anything (and everything) without really understanding how a treatment, unlikely to help, will drain the system.

 

Back when healthcare consisted of bleeding patients with leeches, this conversation was probably a whole lot easier and less complex!  After all, when treatments were ineffective and cheap, well, it wouldn’t really be an issue to consider in writing your Declaration to King George.  After all, wooden teeth and leeches don’t really do much anyways.

 

In fact, the conversation sometimes gets even worse.  If we have time, and aren’t interrupted by a critically injured trauma patient arriving in the ER, sometimes we wonder about another important parameter of the discussion:  “Is healthcare a right if it costs so much that it cripples your country’s finances?  What if it’s so costly that it affects whether your society as a whole can pursue life, liberty, and its happiness?” Difficult question.  It goes to the balance of individuals’ rights versus the rights of society.  That’s never easy.

 

Right now, in the US, we spend an outrageous amount on healthcare, especially for the quality outcomes we see in terms of our longevity and infant mortality measures.  By far, year after year, we spend a larger percentage of our GDP on healthcare than any other country.

 

Fellow citizens, this is exactly where we stand:  a fundamental struggle between whether or not healthcare is a right, and, if so, how much?  This issue reverberates, I think, throughout policy choices and current town halls across the US.  Its consequences reach from healthcare insurance company board rooms to the halls of Congress to my own dinner table when family wants to discuss.  Now, we see it in the current discussion of Obamacare versus the GOP offering of what comes next.

 

Do we force insurers to cover people who have legitimate issues that put them at a higher risk to those insurance companies, and make the companies do that at inexpensive prices?  Do we revamp the system and attempt to foster individual responsibility for healthcare in an attempt to cut costs?  Do we mandate that individuals buy insurance?  Is it to be an individual solution to our healthcare issue or do society and government solve the issue?  Is healthcare a right or a privilege and, if it’s a right, how much is a right?

 

Now I’ll share with you all how I resolve this every day in my practice as a surgeon.  (Shhhh, don’t tell…)

 

…I don’t.  I don’t solve it at all.  I don’t even offer a solution.

 

Here’s what I do:  I respect patient autonomy.  I teach patients (or their proxy if the patient can’t understand or tell me what they want) and they decide what they want to do.  I arm them with the relevant knowledge (as much as I can without giving them a medical education) and I ask them what they want.  I do that at 3am and 3pm and every hour in-between.  And I make a recommendation usually too just to let them know my thoughts.  Then they decide based on what we can do and how likely it is to help them.  The question is which of the options is worth it to them based on where we can predict it will get them and what they’ll need to go through to get there.

 

Myself and the team I’m on don’t look at whether any patient is insured and nor do we care.  That’s how I do it.  And even if I think the decision a patient makes is not the one I would make or recommend, we execute their plan and continue to help them.  They are the boss even when the situation is difficult, great, or something else.

 

Usually, that clears the situation up.  I understand when I read literature that paints physicians as custodians of resources and expensive tests.  After all, our country has a huge problem with healthcare costs.  However, the patient is the ultimate arbiter of their healthcare.  It seems to me to be a strange place to be to ask the surgeon to indirectly manage the costs of healthcare and other society-level issues and yet focus clearly on the interests of the patient.

 

Take a minute and think about doing that.  Now think about doing it at 2am.  Now think about doing that many times over.  Now imagine doing that with a patient who is critically ill and meeting you for the first time.  It’s a tough at bat every time.  That’s what we do.  I want you to know that because where the rubber meets the road on this discussion is typically when you meet someone like me at 2AM in an Emergency Department, and we are forced (in our first meeting) to discuss whether your family member with late stage cancer would want a surgical procedure for an acute problem…even though fixing that problem won’t improve their quality and quantity of life.  They can’t tell me because they’re “out of it” and so I turn to you as their proxy.

 

After I educate the patient (or you) about what can be done, I share how likely we are to improve the situation with a particular treatment.  I even make a recommendation.  But remember, your surgeon is up to bat at many hours of the day and night.  And we are at bat a lot in situations where you or your family is critically ill and sometimes near death.  It’s challenging to manage all those things in shaking your family member’s hand for the first time when time is of the essence.  I can usually help give you a sense of how likely something is to help you, but imagine how that conversation would go if I went on to say “it’ll help you some, but it’s really expensive.”  Ouch.  It’s not a great idea to put cost management on the surgeon.

 

Really tough to balance the probabilities of a treatment helping you, the effort required on your part, and then asking you to balance whether it’s worth it for the cost.  Tough to ask you to do that.  Tough to ask me to do it.  Especially if you, the patient, are really sick.

 

This article calls upon all of us, comfortable now in normal hours instead of in a difficult situation at a 2AM Emergency Department, to begin to make up our mind as a country about whether (and how much) healthcare is a right.  In fact, the time we should decide is before we are ever faced with such a terrible decision.

 

Nowadays, our current state is that we do the best we can.  It would help us a lot to have clarity on the topic of whether healthcare is a right or a privilege because it would make what we can do for you much more clear.  The clarity of black and white, not the gray of indecision, helps us a great deal in achieving the bright lights and cold steel of the operating room should that be what you need.

 

My resolution for all of these complex issues is to educate whenever possible and execute the choice you make about your care.  I’ve never met a patient where my concern is whether you have insurance or whether I can save money on your care.  I don’t know what that patient looks like in whom I could apply the society level issues to individual care.  Would that patient look like my daughter?  My parent?  So where I have resolved this issue in my practice by arming you with what I know in a situation, making a recommendation, and then respecting your decision, it sure would help if our society writ large would solve some of these issues.  It would help at 3AM in the Emergency Department and it would help as we look to revise Obamacare.

 

There are cost-savings opportunities in healthcare.  Lots of them.  Importantly, many are not rooted in the individual conversations between patient and their doctors, and instead flow from system-level waste.  With my quality improvement hat on, I can share that it’s a good idea to build better systems rather than rely on one-off conversations at odd hours that vary greatly from case to case if we have an interest in eliminating waste in our system.

 

Whichever approach you like to improving healthcare, a consensus on whether, and how much, healthcare is a right would make it much easier.  Our indecision as Americans, I think, lurks behind our current situation and many of the interactions in healthcare every day.

 

So on a day to day basis with each patient, one after the next, I do not resolve the issue of whether it’s Obamacare, a GOP plan, healthcare as a right or healthcare as a privilege…but I ask that question about the Declaration to prompt discussion.  I’ve asked more than 223 times now.  Because, as I see every day at work, the fact that we as Americans struggle with this fundamental issue affects so much in the lives of people and their families.  There is no easy answer, yet now is the time to realize for our own goods that we are called to action to solve our healthcare issue as a country in order to pursue our happiness.  It is time to work to enshrine our thoughts on where and how exactly healthcare fits in our lives.  Let’s get this done to make our next 3AM at bat, whether as doctor, nurse, or patient much better for everyone.  Should Mr. Jefferson have one more item on his list?

 

 

 

David Kashmer is a trauma surgeon and Lean Six Sigma Master Black Belt.  He writes about data-driven healthcare quality improvement for TheHill.comInsights.TheSurgicalLab.com, and TheHealthcareQualityBlog.com.  He is the author of the Amazon bestseller Volume To Value, & is especially focused on how best to measure value in Healthcare.

Coming Soon: The Musing Medic

Editor’s Note:

 

Hello All,

 

As you know, we’re searching for original voices and we appreciate all the interest so far!  In the next few weeks, you’ll meet some of our colleagues who are looking to share their unique voices.

 

We continue to feature original voices from the front lines of medicine because the unique issues they see tell us in which directions to innovate.

 

Our colleague, The Musing Medic, focuses us on unique, evidence-based prehospital care and related issues.

 

We think you’ll enjoy our colleague’s take on things as much as we do.  Enjoy the read.

 

David

The Idea: A Sandbox Hospital To Test Our Systems

 

Click play for the audio version of this entry:

 

 

 

The Cost of Poor Quality Justifies The Concept of The Sandbox Hospital

Did you realize that the costs of poor quality are incredibly high in most systems?  It turns out that the median amount of cost recovered from a lean or six sigma project is approximately $250,000 in healthcare.  Because the costs of poor quality are so high it is critically important to focus on quality.  Like we have discussed previously on the blog, one of the challenges in healthcare is that routine and classic healthcare accounting systems don’t make these high costs associated with poor quality very clear.  Some of the other issues exist with the fact that reimbursement is not linked directly to quality in many cases.  Here, let’s talk about a useful idea that could really help improve quality:  the sandbox hospital.

 

Most Quality Issues Are In Fact System Issues

Before we describe the sandbox, consider the idea that most quality issues are in fact due to system issues.  Yet again, I’ll say this concept is very different than what I was taught in the residency and fellowships I performed.  However, on reflection and review of data, this is true.  It’s actually a very common theme in the quality control literature.  Although we in healthcare tend to focus on human error, in fact, the manner in which a system is designed can make human error more or less likely.

 

Look:  if you saw a train coming at you and you didn’t get out of the way whose fault is that?  Well, similarly, we can see human error coming.  If we continue to see human errors in the system, and have the ability to make them less likely by building the system a certain way (FYI we can do this by the way)…well, you see where this is going.  If we can design a system that reduces human errors it’s sort of silly NOT to design a system, based on DATA, that reduces those errors.  I mean, come on!

 

…Not Just Human Factors.

After all, we can imagine that having a surgeon who worked 200 hours in 10 days in a hospital, with minimal support staff, in a environment that had more than thirty trauma activations an hour we would be apt to have some delayed diagnosis or quality issues, right?  We are using the extreme case to indicate how silly it is to pretend human errors sit in isolation from circumstances.

 

Hey, to all the “blamers” out there:  the world is complex and things are multifactorial.  This doesn’t excuse human error, yet the pragmatic way of looking at it helps us reduce it rather than beating ourselves up.  When friction abounds in a system and a human error is produced should we really attribute the issue to a human error?  Labeling things as isolated “human error” is the typical fall back position of physician or healthcare provider (doc you don’t work hard enough or you weren’t smart enough).  In fact, most surgeons and healthcare providers are incredibly dedicated, bright, and sometimes hampered by ineffective systems.  They didn’t suddenly become foolish after being some of the top students in high school and college.  So the truth is:  real process improvement takes work, and labeling things as isolated human error is kind of, well, lazy.  Or, worse yet, labeling things as isolated human error may lead us to turn over our healthcare provider staff (a bandaid solution) rather than allocating resources to improving the system.  You’ll find, if you replace the offending physician, you will have often continue to have similar human errors.  (I promise.) So, FYI, human error is only part of a bigger story.  Again…I promise.

 

Poka-yoke Is The Design Philosophy “Design The System To Make It Easier For People To Give The Output You Want”

Guess what?  There’s even a design philosophy we use in Lean and Six Sigma called “poka-yoke”.  It means “make it easier to do the right thing”.  If you want people to be in the trauma bay within 15 minutes, for example, make it easier to get there.  Put it close to the call room, get some prehospital notification where possible, or do something to reduce the friction in getting there.  Remember, the solutions you use don’t have to work every time.  They just need to make it more likely that the desired outcome will occur.

 

Ok, ok.  I’ll get off my soapbox.

 

Finally…The Concept Of A Sandbox Hospital

Now enter the concept of a sandbox hospital.  If you accept the idea that quality and functional systems are key to deliver excellent care especially with respect to the complex systems in place nowadays, consider how important it is to have effective systems in the hospital.  Now consider how funny it is to roll out things like new electronic medical records and similar large scale programs to a hospital without piloting them first.  Experience with roll outs and innovation literature focus us on multiple ideas to reduce the silliness of rolling out a new system to the entire organization all at once.

 

There are terms for innovation labs and other entities that work within organizations to build and pilot new ideas.  A skunkworks is an entity within an organization that focuses on being an innopreneur in distinction to an entrepreneur.  A skunkworks facilitates thinking differently than the company at large and can avoid being victimized by the company’s culture.

 

To set up an effective skunkworks, it is important that the system at large not feel threatened by the skunkworks, the staff within it, or the results from its workings.  Wouldn’t it be interesting, then, to have a “sandbox hospital”?  A sandbox hospital is a microcosm of an entire hospital used expressly to pilot roll outs of new large scale initiatives on a smaller scale and to innovate new systems.  If you’re into Six Sigma, you could even think of it as giving an easier way to perform Design of Experiments (DOE) for healthcare.

 

This would minimize the cost of poor quality and dropped revenue seen when large scale initiatives (like rolling out electronic medical records) occur.  Hospitals:  spend some time thinking about how to rollout big initiatives to avoid dropped revenue, quality issues, and patient care problems.  Put it in the sandbox and learn your lessons there (!)

 

Specifically, a sandbox hospital would be a free standing facility that could be utilized by different healthcare systems with their providers, culture, and systems.  In other words, it would be a healthcare facility in which they could experiment with how things will look as they roll out a new system.  It would be a sandbox for precisely the reason that it would be a safe area to play.

 

Ethical Ramifications of the Sandbox Hospital

 

There are some interesting questions which are ramifications of this idea.  For example, could the Sandbox Hospital treat patients?  My answer to this is yes definitely.  The Sandbox Hospital would be staffed by providers and other participants from the larger healthcare system that seeks to pilot the new initiative or dream up a new system.  The staff would be equipped with laboratory tests and all the things required to practice medicine.  In fact the only thing that would vary is the new roll out or new initiative being tried for a mode of care delivery.  We could tweek other things to simulate patient flow through the ED and beyond, although this would be more difficult owing to the ethics of potentially turning away patients to control flow rate.  But it’s ok, we could figure it out.

 

The medicine, technical prowess, and cognitive dimensions of practice would not change substantially.  Therefore, patients could be treated at the Sandbox Hospital and it would be disclosed to them that they would be in hospital during the roll out of a new initiative.  However, the Sandbox Hospital would be continually rolling out new initiatives.  We could tell the patients that too.  The interesting thing, again, is that it would be staffed with a portion of the various specialties or systems involved from a ‘mothership’-type healthcare system.  No matter how you feel about rolling out a new system to patients in the Sandbox Hospital, think of how much better it will be than just trying your new thing on ALL the patients who come to the larger healthcare system.

 

I feel the Sandbox is much better than the alternative which currently occurs.  That is, new initiatives are rolled out to health care systems as a whole.  It is challenging to roll out these initiatives while maintaining revenue and, more importantly, quality of care.  And this is fairly high stakes and high risk!  What if the new initiative, for example, grinds the ORs to a hault?  That new initiative suddenly becomes very expensive.  A sandbox hospital, and any costs associated with one, are sort of a hedge against that level of risk.  Better to spend money on a small experiment than a big failure!

 

Consider the ethical ramifications of the Sandbox Hospital.  In fact, it seems that the concept is actually more ethically satisfying than what we typically do in healthcare, in that it focuses on safety and could have failsafes, etc., built in with a stop-the-line patient protection measure.  Currently, when a new initiative is rolled out in the hospital, it is often up to the hard work of the residents, nurses, advanced practitioners, or other physician staff to get around the fact that the health record or physician order entry system just plain doesn’t work.  A Sandbox Hospital would help staff anticipate those opportunities and focus on expected issues to eliminate the problems with a larger roll out.

 

At the end of the day, a Sandbox Hospital would likely be cost effective in that it would decrease the risk of catastrophic failure of roll out for a new system to a hospital.  Sandbox Hospital could help with roll out to operating rooms, etc.

 

Some possible downsides of the Sandbox?  Yes, it is possible that staff from the mothership hospital running the experiment will act differently in the new venue–it’s still better than the alternative of “hey let’s try this in real life first”.  Yes, there would be some variation compared to the larger system, but a small scale model like this may help us avoid the cost of poor quality seen with larger roll-outs.

 

In other words, the type of errors being watched and tracked in the larger hospital system may not exist once the electronic record comes, but very real other errors do exist and a Sandbox would let us see them.  And, of course, the systems can be sold as cost saving (“hey where’d all the unit clerks go?”) and quality improving (“we don’t have to read all that handwriting anymore but hmmm now the notes say the same thing everyday…).  We feel that near-miss events and medical errors of a different type may actually be at play and again we see a justification to try a new system in the Sandbox first.

 

At the end of the day, the Sandbox Hospital would be a highly ethical, cost effective, small-scale “experimental” hospital. When we say “experimental”, we don’t mean the medical care delivered to patients would be anything less than excellent. When we say “experimental”, we do not mean that we would be experimenting with medical care.  When we say “experimental”, however, we mean that the Sandbox Hospital would be constantly rolling out new initiatives at the behest of the medical centre supplying it with staff and culture for a certain time.  This would allow the collection of data regarding the failure modes into which the new system deployment may enter.  The rationale for the sandbox hospital is that it is much cheaper to fail quickly and effectively on a small scale than to fail catastrophically or partially with a roll out to a major healthcare system.  The Sandbox Hospital may minimize pain of deploying new systems and would improve patient safety on the whole by obviating patient care issues that occur during major rollout.

 

Call For Your Comments and Thoughts

If you are reading this, you may have participated in one of these roll-outs, such as the often-cited new electronic medical record rollout, we would love to hear from you with respect to how this influenced down time, physician order entries, and near-miss type events.  For example, although we are often instructed that physician order entry decreases medical error, some of us feel that an electronic medical record actually changes the nature of the medical errors.

 

As physicians and healthcare providers, have you seen major problems during the roll out of new administrative plan or system? We would love to hear from you below. Experiences like yours give us the foundation on which to build the sandbox hospital in the modern day.