Health Care Elsewhere

“Well Julie, the move into an apartment from the house that was our home for 40 years has been accomplished.  It required a lot of physical labor and, as you mighty expect, was accompanied by a bit of emotional trauma.  It’s almost refreshing to return to thinking about health care.”      

“I welcome your weary mind and fatigued body back to the blog, Curmudge.  You know, I seem to recall that as you got older you became less adventuresome in selecting foreign countries to visit.  Was that because of concerns about their health care?”

“Sanitation, Julie, as well as health care.  Even in countries where the water was good, Mrs. Curmudgeon drank bottled water and I drank beer.”

“At the end of our last discussion you promised to tell me about health care in other countries.  From these countries’ experience, we will attempt to learn how a complex system like health care can be centrally managed.  Although one can’t go into much detail in a blog, perhaps you can mention some of their key features.  More complete data are available on the Web.”

“Let’s start with Switzerland, where the health care delivery system seems to work well.  In Switzerland 99% of the citizens are covered by nonprofit compulsory universal health insurance called LAMal.  LAMal is a multi-payer, private, nonprofit insurance system with over 70 different plans, and it is financed by premiums and by government subsidies paid for low-income individuals.  Overall, the Swiss system might be considered a public-private combination.  Coverage cannot be denied on the basis of poor health.  In 2007, government health expenditures were 19.8% of total government expenditures.”

“With 26 cantons (states) and four official languages (the fourth is Romansh), one would think that Switzerland would be considered a complex system, as we discussed last time.”

“Perhaps, Julie, but with only 7.6 million people and a propensity for doing things right, I would think otherwise.  Their most obvious unifying characteristic is their ability to efficiently extract money from tourists.  I know; I’ve been there.”

“I believe, Curmudge, that the United Kingdom is next on your list.  Their publicly-funded single health care system, the National Health Service (NHS), provides care free at the point of service to all legal residents of the UK.  Physicians are technically self-employed and provide services under contract with the NHS.  Many ‘moonlight’ and see patients outside the system.  The general practitioners serve as gatekeepers for access to specialists.”

“Traditional problems with the NHS have been access and waiting times for specialty care.  One feature most familiar to Americans is their National Institute for Clinical Effectiveness (NICE) for assessing the evidence for the clinical and cost-effectiveness of drugs and medical procedures.  Recently the government has increased taxes and health care spending to cover the cost of the aging population.”

“I’ll summarize the UK, Curmudge.  Their system appears to work fairly well, especially if one is not very sick.  Americans would dislike long waiting times and would have reservations about the NICE committee.”

“Let’s take the Chunnel to France, Julie.  Get ready for better food, a different language, and a different health care system.  There almost everyone is covered by public universal insurance (Securité Sociale) paid for by the government.  Ninety-two percent of the people purchase additional private insurance to pay co-pays.  The government pays for the supplemental insurance of low-income people, and the supply of hospitals and clinicians has helped France avoid the problem of long waiting times.”

“Apparently, the lack of gatekeeper protocols has driven the system into economic deficit.  So what is the value of a good system that is not sustainable?”

“One intriguing feature of the French Securité Sociale card is that it contains microchips storing a person’s medical record.  It also provides for immediate reimbursement of a patient’s out-of-pocket co-pay.”      

“For our final health care thumbnail, let’s go to the other side of the world to Singapore. Wow, Curmudge!  That was sure a long plane flight.”

“The health care system in Singapore is based on compulsory medical savings accounts (Medisave) and voluntary catastrophic insurance (Medishield).  Payment for this insurance comes from an individual’s Central Provident Fund (CPF) that is funded by 40% (half from employee and half from employer) of his wages.  There is also a government-sponsored safety net program (Medifund) for those with insufficient resources in their Medisave account.  But despite the apparent success of its National Health Plan, Singapore will be facing rising costs due to growth and the aging of its currently young population.”

“Okay, Curmudge, it’s crunch time.  We know that health care delivery is inherently complex, and we have just learned how several countries—large and small and more or less complex—are dealing with it.  We also know that expenditures for health care are getting out of hand most everywhere.  If you have a solution, tell us about it.  Jump on your horse and spread the alarm; ride through every village and farm.”

“Actually, Julie, I believe it’s nap time.  We’ll talk more about this in our next conversation.  Don’t go away.”

Kaizen Curmudgeon 

Complex Systems

“Curmudge, for the past five years we have been, figuratively, shouting from the rooftop, ‘Adopt a Lean culture in health care.  It will reduce waste and increase efficiency and patient safety.’  You want to do something different?”

“Not really, Julie.  Now that we are in an office building downtown, shouting from the rooftop would be a bit impractical.  We’d be a blip on the Appleton skyline and would attract the attention of the building management and local law enforcement.  We’ll stick with writing, and our topics will include broader health care issues as well as Lean.  Our next subject will be complex systems, a system composed of interconnected parts that as a whole exhibit one or more properties not obvious from the properties of the individual parts.”

“Please elaborate, Curmudge.  Some examples would be helpful.”

“Complex adaptive systems are special cases of complex systems. They are complex in that they are diverse and made up of multiple interconnected elements and adaptive in that they have the capacity to change and learn from experience. Examples of complex adaptive systems include ant colonies, manufacturing businesses, and health care.”

“Finally!  I am now with you.”

“These are a few characteristics of complex adaptive systems:

System behaviors may appear to be random or chaotic.

They are composed of independent agents whose behavior is based on physical, psychological, or social rules rather than the demands of system dynamics.

Because agents’ needs or desires are not homogeneous, their goals and behaviors are likely to conflict. In response to these conflicts or competitions, agents tend to adapt to each other’s behaviors.

There is no single point(s) of control. System behaviors are often unpredictable and uncontrollable, and no one is ‘in charge.’ “

“Gosh, Curmudge, if one can get past the social science jargon, it’s beginning to sound like health care.”

“Here’s more that speaks directly of health care, written by engineers:


‘A complex adaptive system such as health care is not amenable to the controls and feedback forces we (engineers) generally ascribe to a system.’

‘Health care delivery today is in turmoil. Despite rapid advances in medical procedures and the understanding of diseases and their treatment, the efficiency, safety, and cost-effectiveness of the delivery of health care have not kept pace. Improvements in the delivery of services in other industries have simply not been transferred to health care.


The question is why not.  Here are a few of the most obvious reasons.


For one thing, the third-party reimbursement system is not conducive to a competitive environment in which customers (i.e., patients) can seek out the most cost-effective treatment or provider.


Second, health care delivery is still a cottage industry in which many components of the overall system operate as independent agencies.  (As described by Levy, physicians practice the “craft of medicine” in which each functions as an independent expert.)


Third, the quality of care delivery and benefits are difficult to quantify. Finally, the annual cost of health care is increasing by double digits.’ “

 

 

“We’ve already mentioned some of these issues, most recently in our posting on Puzzlement.”

“Those observations, Julie, appear to be reasonable, at least to you and me.  And I suspect that most people would agree with the quote above that, ‘Health care delivery today is in turmoil.’  Further, we have learned in the past 5 minutes that a reason for the turmoil is that health care delivery is a complex adaptive system and that in such a system no one is (or can be) ‘in charge.’  ‘These systems are so complicated that no one person can fully grasp everything that is going on.’ “

“Sometimes, Curmudge, I can’t even fully grasp everything that is going on with my family.”

“Then you can appreciate how difficult—perhaps impossible—it is to manage a complex system like health care delivery across a large nation like the United States.  Here are some more reasons:


‘There is no reliable model of the health care sector.  Price doesn’t play the same role in health care as it does elsewhere in the economy.


Complex systems have unintended consequences.  In trying to solve one problem we create other problems.


Complex systems cannot be managed from the top down.  People in Russia now admit that the Soviet Union didn’t understand enough about their entire economy to manage it all from Moscow. ‘ “

“I’ve got it Curmudge—sort of.  But if centralized management of health care delivery in the U.S. is fraught with difficulties, how do other countries with centralized health care do it?”

“We’ll tackle that next, Julie, but we may have to wait an extra week for our discussion.  I’ll need to take some time off to move from the big house that I shared with the late Mrs. Curmudgeon into an apartment.”

  

Kaizen Curmudgeon

"A Puzzlement"

"Here’s today’s trivia question, Julie.  Our title was a song in what Broadway musical?”

“You know very well that I’m not a child of the 40’s or 50’s, while you, Old Relic, were dating the future Mrs. Curmudgeon in 1954.  Of course I don’t know the song’s origin.”

“The King and I, Youngster, and it was sung by the King, Yul Brynner.  More familiar songs from that show are ‘I Whistle a Happy Tune’ and ‘We Kiss in a Shadow.’ “

“I’m going to need some guidance in finding a link between this particular show and Lean or health care.  You take the lead.  ‘Shall We Dance?’ “

“There are lots of puzzling aspects to our system of health care delivery.  It’s not that I don’t comprehend them; I just find them peculiar.  Lots of other people also find them a bit incongruous, that is, they are not always consistent with the triple aim of providing the best care for the whole population at the lowest price.”

“Whew!  I was afraid that this whole posting was going to be written by Rodgers and Hammerstein.  So Curmudge, you list your puzzlements, and I’ll sit over here and be…er…puzzled.  I suspect that the reason for many of these issues is evident but the rationale is, to say the least, fuzzy.”

Puzzlement: Although the nation is hoping to hold down health care expenditures, why haven‘t physicians’ needs to practice defensive medicine been resolved?  Comment: We know the answer, but why isn’t something being done about it?

Puzzlement: If health care is virtually free for many patients, e.g.. Medicare and Medicaid patients, and providers are paid based on production, why are we surprised that the use and cost of health care are increasing?

Puzzlement: Why don’t buyers (patients) know the prices of the products (procedures) that they buy?  For that matter, why don’t the sellers (providers) know the prices either?

Puzzlement: Why, in Wisconsin, does the cost of a knee joint replacement range from $17,000 to $55,000?  (At least someone knows how much a procedure costs.)

Puzzlement: If a Medicaid patient needed the services of a convenience clinic down the street from where she lives and the clinic’s listed price was higher than what Medicaid would pay, why would a law be broken if the patient paid the difference?

Puzzlement: Why can’t a person purchase health insurance from any insurer he wishes irrespective of the state in which the insurer is located?

Puzzlement: Why are health insurance policies purchased by an individual and an employer treated differently by the Internal Revenue Service?

Puzzlement: Why is a ‘Full Code’ the default order for a patient who is obviously on the brink of death?

Puzzlement: Why won’t (usually) the Food and Drug Administration authorize a promising therapy for terminal patients before it has received their full approval?

Puzzlement: Why do substantial numbers of people in the U.S. believe with almost religious fervor that someone else—government or employers—are morally obligated to pay for their health care?  In that scenario, reimbursements are administered prices; and ‘providers and patients are insulated from market pressures that would normally force efficiencies, greater accountability, and the delivery of increased value’ (1).”

Puzzlement: Decisions about health care are inherently personal, ranging from what we will eat for breakfast to who will do our surgery.  Each of the almost 313 million people in the United States makes these decisions every day.  How can a government committee make personal health care decisions for such a large and diverse population?  Comment: A large, diverse mass of people is an example of a complex system.  This will be discussed further at a later date.

“My turn, Old Guy.  Here’s my puzzlement.  You really sound like a cantankerous curmudgeon today.  Is there a reason for that?”

“Of course there is.  I have to do that occasionally to maintain my reputation.  I certainly wouldn’t want to be called the Kaizen Pussycat.”

Kaizen Curmudgeon

(1) Christensen, Clayton et al.  The Innovator’s Prescription  (2009, McGraw-Hill)

Health Care Outcomes—The Rotator Cuff

“As you might expect, Julie, as a senior citizen many of my friends are also senior citizens.  And as a volunteer in health care, my senior citizen friends tend to share with me their poor health care outcomes.”

“Curmudge, I recall that some of those outcomes have occurred pretty close to home, like your college roommate in Stan’s Story and Ms. Curmudgeon in A Day in a Hospital in Prague. “    

“As it turned out, my wife’s problems weren’t over when she returned home.  The fall in Prague had torn her rotator cuff, which now needed surgical repair.”

“Clear the track!  I think another medical anecdote is headed our way.”

“After waiting several weeks to get on the doc’s schedule, my wife went in for arthroscopic surgery on her right shoulder.  Regrettably, the screws (or whatever) were observed to pull out, so the doc had to finish the job via open surgery.  After several weeks of therapy, an MRI revealed that the results of the open surgery hadn’t held, either.”

“What a bummer!  So Ms. Curmudgeon couldn’t raise her right arm all the way.  That’s quite a disability for a professional organist and choir director.”

“I found it interesting, Julie, that the Medicare Summary Notice showed two CPT (Current Procedure Terminology) codes for my wife’s rotator cuff surgery.  One was for the arthroscopic surgery and one for the open surgery, neither of which was successful.  If it weren’t for the two CPT codes, it wouldn’t have caught my eye.  It would appear that the doc was paid the same, irrespective of the outcome.”

“That’s the system, Curmudge.  Outcomes are not factored into reimbursements.  And because Ms. Curmudgeon was covered by Medicare, the citizens of the United States paid for two unsuccessful surgeries.  As we quoted Dr. Groopman in an earlier posting, ‘No one can guarantee the right outcome from a treatment for an individual patient.’ ”

“I guess that’s one reason why reimbursement systems based on outcomes are problematic.  One would think that qualifiers might at least be added to the bill…perhaps an ‘attaboy’ for a success and ‘oops’ for an obvious failure.”

“No physician can afford too many ‘oopses,’ Curmudge.  As you said earlier, patients—especially senior citizens—don’t hesitate to talk about their health care experiences.”

“The surgeon put in a full morning’s work and was paid for his efforts, but he was probably as frustrated as we were.  Perhaps the shoulder was truly beyond repair.  This was a story with no happy ending for anyone.”

“Paying for procedures and not outcomes is one of those ongoing problems in today’s health care.  My guess, Curmudge, is that we will discuss this further.”

Kaizen Curmudgeon