Best Selling Author and Surgeon Gave Leaders of the Catholic Health Ministry Examples of Putting Together a Mosaic Revealing a Community's Health Issue
ATLANTA (June 6, 2011) — We are battling over what it means to lower the costs of patient care without harming a soul, said Atul Gawande MD, keynote speaker at the 2011 Catholic Health Assembly meeting in Atlanta, June 5-7. "I am afraid we are paralyzed by the battle, that we are in inertia. But this is the fundamental issue of our generation."
Providing better health care at lower cost is a puzzle that has countries around the world struggling for solutions. Answers are not going to come on the state or national level. They are closer to home, at the community level, Gawande said.
A writer and practicing surgeon, "the job has changed," Gawande said. Where physicians once were expected and encouraged to make autonomous decisions and exercise their knowledge and expertise, the world of medicine has simply gotten too big for any one practitioner to work independently. "There are 13,600 different ways the human body fails," he said, leading practitioners to specialize and super-specialize.
But physicians need to stop operating as autonomous cowboys and start approaching medicine as members of pit crews, teams that work together in patient care. To create health care teams effectively, he said, requires four skills, and it all starts with collecting data, an unaccustomed practice in health care, and looking for patterns.
"If we imagine a system coming together around patients, we begin to see we need data," he said. "Data is not sexy but it is the most important component," especially if physicians and health care systems expect to devise new ways of delivering the best care at the lowest cost.
The federal government can track the unemployment rate on a county by county basis, "but we have nothing like that kind of information about heart attacks "and whatever public health information we do have is likely to be several years old."
Yet Gawande gave examples of putting together a mosaic revealing a community's health issue, piece by piece: Almost 50 percent of a health care system's costs are associated with 5 percent of its patients. Many of them suffer from asthma. Further investigation reveals a specific asthma patient has additional, unrecognized health problems that require care, including help with his medication, and others in his family also suffer from asthma. A home visit shows the family has no vacuum cleaner and the house is full of dust and mites. Supplying a free vacuum cleaner turns out to be a cost-effective solution to improving the whole family's health, not to mention eliminating their emergency room visits.
This, Gawande said, is an example of the second skill for creating a team model of health care: the ability to devise ways to address problems revealed in examining data. Another example, one he knows well, he said, is the simple checklist. Gawande, who has written a book on the topic, helped run a project that used input from the aviation industry to devise a 19-point checklist for use in operating rooms to bring down the rate of mistakes, complications and related deaths. As a surgeon, Gawande said, he resisted the idea that a checklist could make much difference in surgical outcomes or complications. But the checklist went into use in eight hospitals around the world, he said, "and what we found is that every hospital had a drop in complications, and it cut deaths by 47 percent."
"What this tells us is that [data analysis gives us] an opportunity in defining at a very detailed rate what we are going to do to improve care for patients," he said.
The third skill is the ability to implement a new program or procedure at scale. There is always a group of about 20 percent who resist or plain refuse to make changes. "People have a difficult time going from cowboys to pit crews, and we are slow to grapple with this," Gawande said, adding that this resistance doesn't come only from practitioners.
An innovation that demonstrates a great new model of care for asthma patients also demonstrates a great drop in revenue for a hospital for which asthma admissions are a significant source. This situation points right back to teamwork - perhaps showing the data to payers and asking them to help create a new payment system to make this innovation in care possible.
"My impression is that you feel completely set upon," said Gawande, speaking to an audience full of health care leaders. "The fourth skill is prioritization. Pay attention to where the costs are."
"The sickest people are often the people we fail the most," he said. If 5 percent of our patients account for 50 percent of our costs or more, "look at your community's 5 percent to see where your portfolio of projects are going to be — get the care to that percentage of patients who account for the majority of the costs."
The Catholic Health Assembly is the largest annual gathering of leaders of the Catholic health ministry. Organized under the theme, "The Opportunity Now; How Reform Will Advance the Healing Mission," the sessions examine the opportunities, the challenges and the realities of implementing the new health reform law. The program is presented by the Catholic Health Association of the United States (CHA).
The Catholic Health Association of the United States (CHA), founded in 1915, supports the Catholic health ministry’s commitment to improve the health status of communities and create quality and compassionate health care that works for everyone. The Catholic health ministry is the nation's largest group of not-for-profit health systems and facilities that, along with their sponsoring organizations, employ more than 750,000 women and men who deliver services combining advanced technology with the Catholic caring tradition.