The Obama administration is focused on the costs, which is a big and growing problem. But, is that THE problem or merely one of several symptoms that need to be addressed by focusing on the root causes (which is what any good practitioner will tell you). Not sure I have all the answers, but I would like to share a few thoughts on what (I believe) is fundamentally broken. I refer to them as the 3 C's:
Continuity
Years ago, we used to have primary physicians (internists) who spent time with each patient, got to know them on a personal & physiological level, and made sure to review any services provided by 3rd parties or specialists. They oversaw our treatment and ensured there was continuity of care as the patient flowed through the system. They were there to ensure no one made any hasty decisions (rush to diagnose and/or judge a patient's condition). They were there to ensure the patient's psychological needs were met on an equal and balanced level with the physiological needs. They were well compensated, and they were the critical link to ensure the patient got through the system with the right diagnosis, the right treatment, the right support, at the right time. The concept of the primary care physician has been turned into a form of industrialized medicine, which focuses on Cost, Time, and Productivity instead of desired outcomes for the patient (which is the only measure of success that ever matters). This is a shame for a once proud and revered position. These physicians were integral to our care as patients and their deep understanding of the patients needs is what allowed the US to create the best healthcare system in the world (not the technology, not the drugs, and not the single minded focus on evidence-based medicine). They were the only ones who provided a holistic understanding of all our needs (they balanced the evidence against the desired outcomes).
Today, these physicians (internists) have been emasculated by the combination of industrialized medicine and increasing weight of litigation. Both of which have promoted a culture of defensive medicine, limited time for introspection & causal analysis, and reduced the ability of the physician's to improve their core skills as diagnostician. Physicians rely on numerous tests and 3rd party experts to interpret the tests (based on analytical models, which are still evolving) instead of their intuition and years of careful listening and observation about their patients.
Physicians all too often are quick to prescribe rather than probe at a deeper level (again due to the limited time with each patient in order to meet quotas). Lean models do not support introspection nor do they fully encapsulate an understanding of desired outcomes required to promote the development of diagnostic skills to improve patient outcomes and overall results.
On more than one level, the pharmaceutical industry is complicit with this model as it promotes pattern matching to "their" preferred method of treatment instead of what may have (at one time) been a different practice for addressing the patient's needs. Medication used to be dispensed with much greater care (OTC and prescription-based). It's far too prevalent and many people take it for granted when they consume all these pills and drugs as if they (or anyone) truly understands how the "chemistry set" works in our individual cases. That won't be known for a number of years, yet we continue to play with known and unknown toxicities and yet we are surprised to see the rise in cancers, drug resistance, and reemergence of once dormant diseases.
One has to wonder why all the emphasis on "big data" is focused on treatment and not on prevention. Instead, we fund individual silos of research that look at opportunities for causality (patterns that may provide insights to symptoms and/or health related concerns). Why is big data not focused on the introduction of food (directly in our systems), chemicals in our environment (indirectly in our systems), and the numerous other environmental factors that can penetrate our fragile cavities and cells (to say nothing of the combinatorial of interactions) ? In almost every case, solving the root cause (which often takes far more time to identify & isolate) produces a better set of outcomes and reduces undesired outcomes.
Communications
Well, this one is based on a combination of personal experience and many accounts related by others (some of whom are practitioners). For years, we've seen the emphasis on "follow the patient or patient flow", but the emphasis is placed on the lean aspects and not enough on the assurance of handoffs between practitioners, departments, and organizations. Yes, EMR will help...but don't kid yourself. There is far more to conducting a proper handoff that addresses the desired outcomes of the customers (patient, their family, the providers on both sides of the handoff, and the organizations).
Perhaps more importantly, are the communications that are provided by practitioners to patients and their families. Many feel that discussing the truth in a factual manner with patients is a necessary and obligatory part of good medical practice (gmp). In many situations, it is...but not in every case. Let's take the scenario of someone who has a history of anxiety and/or depression (or perhaps both). Can you imagine the impacts of conducting a factual discussion with a patient with this history who is dealing with a serious illness and/or terminal condition ? It's not enough for the practitioner (physician or nurse) to perform their job and deliver the "news" (good or bad). The unintended consequences of the wrong communications (right information delivered in the wrong manner or the wrong information delivered at all), can undermine and even destroy a patient's hope. That line should NEVER be crossed by a practitioner (any clergy will tell you that hope is the most important thing to a human being). I have personally seen this line crossed numerous times and it is shocking to see the ignorance of the practitioners when confronted about the impacts of these communications. Amazing that these simple concepts are not properly conveyed in school and consistently enforced in practice.
One of the more disturbing aspects of problematic communications is the open speculations that many practitioners engage in with patients. IFF this is absolutely necessary, there must be some guidelines set by the CMO as to how these are conducted. This is not about "playing HOUSE (popular TV series)". Can you imagine brining your car to the dealership and listening as they mechanic speculates on the possible problems with your automobile ? Or perhaps if your lawyer is speculating about all the risks you may encounter with a particular deal you are trying to conduct with another organization ? Your expectations from a professional is to provide expert guidance and lead you to a course of action that minimizes your risk and maximizes the desired outcomes you are trying to achieve. Just imagine the conversation a young couple has with a nurse practitioner who examines their child and says she "think the daughter may have a neurological problem" because of a few patterns that the nurse may have read about and is now attempting to apply in a speculative manner. The couple then seeks out another physician who later indicates that there is nothing wrong with the daughter...it's a common set of symptoms with young girls who have been exposed to a certain environment or stimuli. The reason for the discrepancies is not important. The fact that it occurred at all is THE Problem ! This happens in every organization and is so common that it strikes me as a huge challenge to the credibility of the medical profession. Open speculation about causality in front of a patient needs to be done with great care as it can negatively impact the emotional jobs that a patient (and their family) are family are trying to address. Further, hurtful speculation (which is when the wrong communications are conducted with a patient and/or family) can undo therapy and progress that patients are trying to achieve (to say nothing of the frustration of the nurse practitioners who are trying to address both the functional and emotional jobs of the patient).
Customer
I prefer the word customer instead of patient. Patient implies someone who must wait (or endure) until the service provider is ready and/or capable of meeting their desired outcomes. Yes, the Latin derivative defines it as suffering because that is how we "recognized" someone in need of care. The term "patient" and it's original meaning are outdated and to a larger extent needs to be left behind. It is time to stop treating people who need healthcare services as patients because we are : (1) tired of waiting for you to get around to attending to our needs, (2) in need of the right care and do not want to be "practiced upon", and (3) paying too much for inconsistent services and poor communications.
While there are always going to be more demand than supply in healthcare, that doesn't mean it can't be driven from a customer centric viewpoint. I realize there is a growing movement for patient-centricity, but that is not a consistent view across the providers, the payers, and the practitioners. I can tell you from personal experience that costs are being taken out at the expense of desired outcomes for patients and their families. The government is trying to "reform" healthcare, but they are attacking the cost structures that have been built up over the years instead of trying to understanding the desired outcomes of customers (patients and their families, the practitioners, the payers, and the providers). Only then will real change happen.
Any organization that aspires to be great is only able to reach that pinnacle once they have invested in a customer-centric approach. Going from Good to Great was never about looking at "patterns" or hiring "level 5 management". That's the same "quick fix" mindset that drives organization's strategy is the same flawed approach that is being used to reform our healthcare system. The focus on reforming healthcare is the same approach used in many companies: It's not about the system…it's about the customers. Same goes for corporate hiring practices. Yes, you need competent people but trying to find flamboyant figures at the top who are turnaround experts will not ensure that healthcare addresses the unmet needs of customers.
Transformative change in organizations and "systems" (like healthcare) only happen AFTER the decision makers change the way they think about the problem. Once they frame it properly, then they can make the right decisions because they are measuring the right stuff. After that, it's just a matter of execution.