By LILAH LOHR
ATLANTA — The nation's health care providers are battling over what it means to lower the costs of patient care without harming a soul, said Dr. Atul Gawande, keynote speaker at the Catholic Health Assembly here. "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, Gawande said. They are closer to home, at the community level.
Gawande, a practicing surgeon, said the physician's job has changed. 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.
In this new health care environment, Gawande said, 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 the first is collecting data — an unaccustomed practice in health care — and looking for patterns in the data.
"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, he said, "but we have nothing like that kind of information about heart attacks" and whatever cumulative public health information the health system does have is likely to be several years old.
Gawande gave an example of what health providers found when they put together a mosaic revealing one community's health issues: 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 part of 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 by examining data. Another example, one he knows well, he said, is the simple checklist.
Gawande, a staff writer for The New Yorker magazine and author of several books, helped run a project, with input from the aviation industry, to devise a 19-point checklist for use in operating rooms. The goal was 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 to scale. There is always a group of about 20 percent who resist or plain refuse to make changes. And this is true of physicians, he said. "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 could result in a great drop in revenue for a hospital for which asthma admissions are a significant source of income. This conundrum calls for teamwork to arrive at a solution. Gawande suggested the providers take to payers the health improvement data resulting from better disease management in order to negotiate reimbursement structures that reward patient-centered innovation.
"My impression is that you feel completely set upon," said Gawande, speaking to the audience full of health care leaders. He suggested health care providers develop the fourth skill, prioritization. "Pay attention to where the costs are," he advised.
"The sickest people are often the people we fail the most," he said. If 5 percent of a provider's patients account for 50 percent of its 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."
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