Thursday, June 11, 2009

Theory of the health care firm

This article by Atul Gawande on Medicare abuse in McAllen,TX has been discussed elsewhere, and it's no wonder that it has created such a stir, it is very thourough and mostly right on. One excerpt:

The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. I asked Cortese how the Mayo Clinic made this possible.

“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.

No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs. “When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” Cortese told me.

Skeptics saw the Mayo model as a local phenomenon that wouldn’t carry beyond the hay fields of northern Minnesota. But in 1986 the Mayo Clinic opened a campus in Florida, one of our most expensive states for health care, and, in 1987, another one in Arizona. It was difficult to recruit staff members who would accept a salary and the Mayo’s collaborative way of practicing. Leaders were working against the dominant medical culture and incentives. The expansion sites took at least a decade to get properly established. But eventually they achieved the same high-quality, low-cost results as Rochester. Indeed, Cortese says that the Florida site has become, in some respects, the most efficient one in the system.


Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of co√∂rdination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

What he's talking about here is the well known issue of assymetric information, where the doctor knows technology and the patient knows only that he's in pain. There are many examples of this besides the housing industry, and generally the free market solution is incorporation. Take computers. Most consumers have no idea what's in their computer and would be lost if they had to construct a computer from its components. So the market solution is to put the assembly of these components under one firm, so that the consumer than has an easier informational challenge in which he need only compare and contrast complete computers rather than all the combinations of components. The analogy with health care is that consumers can't easily distinguish and judge individual procedures but they can easily distinguish and judge health care companies based on their reputation and record of performance.

I believe this is what the HMO revolution was about in part, but we all know it ultimately failed when the consumer got pissed off that someone told them "no". My question is why does the Mayo Clinic apparently succeed at this? Not answered.

And he concludes:

Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.

In El Paso, the for-profit health-care executive told me, a few leading physicians recently followed McAllen’s lead and opened their own centers for surgery and imaging. When I was in Tulsa a few months ago, a fellow-surgeon explained how he had made up for lost revenue by shifting his operations for well-insured patients to a specialty hospital that he partially owned while keeping his poor and uninsured patients at a nonprofit hospital in town. Even in Grand Junction, Michael Pramenko told me, “some of the doctors are beginning to complain about ‘leaving money on the table.’ ”

As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.

One clear way to tip the balance in favor of Mayo and other private providers is to eliminate Medicare as the personal piggy bank of profligate doctors.

Addendum: My brother the healthcare exec emailed me an answer to my question about Mayo v. HMO:

HMOs aren't a single concept. They are at least 2 different concepts.

The first one, which is the one that failed pretty significantly over the last 15 years, is the concept of steering patients into a particular group of providers, and the providers have loose to no other affiliation with one another and close to no ability to "manage" the costs, quality, or service of the system they are a part of.

The second concept is similar to the first, except the providers are significantly integrated and have the ability to collaborate to take costs out of the system and improve quality and service. They also generally have a shared financial incentive through capitation and benefit collectively and individually from costs coming down.

Most of the U.S. experience with HMOs was the first concept, and it left a bad taste in people's mouths. Patients felt restricted in their choices of providers and providers felt they had lost control over decisions and blamed someone else for this, mainly HMOs. The delivery system was essentially a group of individuals with individual interests, some of which were competing and most of which were disconnected from one another, both finanically and from an information perspective. This is largely the system we have in the U.S. today.

There are pockets of the second concept across the country. The article refers to these delivery systems as "accountable care organizations," a term coined in the following article (I have a subscription to Health Affairs if you want me to track down the full article):

It's really just a new term for the
original concept of HMOs (NOT the sham HMOs in the first concept above), Mayo Clinic, and other organizations that have come together to organize the delivery of care, including sharing information and financial rewards collectively. It's a great concept with proven results as noted in the article in The New Yorker. However, it's going to be difficult to move our current system to this model on a dramatically larger scale because it requires a whole lot more Mayo Clinic-types with an organized approach rather than individual providers providing individual segments of a patient's care. The lack of naturally occuring such organizations is why the good HMO concept slipped into more of a sham HMO reality that most of us think of when we hear "HMO."

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