Is David Goldhill Fix For Health Care Right?

First I believe our health care system must be better so I’m always curious to hear how others might propose to fix it. I recently had the opportunity to listen in two conversations with businessman David Goldhill about how healthcare might be made better. Goldhill lost his father to a hospital acquired infection and witnessed multiple errors during his hospitalization which compelled him to write not only a piece in the September 2009 Atlantic titled How American Health Care Killed My Father, but also a new book titled, Catastrophic Care: Why Everything We Think We Know about Health Care Is Wrong (Vintage). The first conversation was with New Yorker writer and best selling author Malcolm Gladwell. The second with Professor Ashish Jha, MD, MPH of Harvard medical school and Harvard School of Public Health. Does his solution offer the right prescription? Maybe. Maybe not.

As a practicing primary care doctor passionate in fixing health care, I was disappointed by the Gladwell interview. I suspect, however, that is because Jha comes from a very different background and the latter’s questions were more insightful and compelling.  (I will discuss my impressions of the Gladwell and Goldhill conversation in a future post). With Jha, Goldhill concludes his conversation by noting that the problems in health care are: excess care, extremely high prices, wide range of quality, gigantic safety problems, and access issues. He believes that many of the failings in health care are because the focus is on the wrong customer. The focus isn’t on the patient. It’s currently on the insurers, Medicare, or Medicaid. As a consequence, the incentives caused by having a third party payor is the reason why health care isn’t operating well. He believes that the country should have a national insurance system where everyone is covered. This does not mean government run. Coverage should be narrowed to catastrophic care.

Health Care is Unfriendly and Unfocused on the Consumer

As an example on how unfriendly and unfocused health care is on the consumer, Goldhill relayed a recent incident involving his 11 year hold child who had symptoms of a ruptured appendix. At the hospital, Goldhill initially filled out an 8 page form listing important information. By his count, he needed to fill out the same form 5 to 6 times during the same stay, including completing another one in the ultrasound department just after filling out the same form in the emergency room. Even after his 11 year old child’s ruptured appendix was successfully removed, he still had to argue with his insurer a month later to cover the surgical procedure.  Goldhill notes that the claim was initially denied because it did not appear to be “medically necessary”. His experience with his father’s illness certainly began shaping his viewpoint. Goldhill believes that for such a large institution like health care to be “careless” it is more than characterizing one entity to be “evil” but rather some sort of systemic or structural issue.

Why is health care performing at these mediocre levels? Goldhill feels that it is because consumers have given health care a pass. Specifically, as patients we only worry about the end result, like having a child recovering after surgery. We ignore the 25 to 30 things that went wrong. Patients must change their psychology; they are “mistaken if anyone is looking out for them”.
Goldhill correctly pointed out that:

• “health care largest costs are in chronic conditions. Much of health care could be managed if patients were more involved with lifestyle changes. We’ve medicalized issues that were in the past were non medical issues.”

In Goldhill’s mind, this is a problem and that as a society, “if it is called health care then we will subsidize it.” He notes that the government is willing to subsidize his cholesterol lowering medication Crestor but would not subsidize his lifestyle change to eat more fish. (One also wonders why Goldhill, who appears fairly young and in good health would even need the newest and most expensive cholesterol lowering medication on the market) .

He observes that more costly innovations are adopted by health care more quickly than less costly innovations. When Medicare cuts reimbursement on a less costly drug, the system as a whole (doctor prescribing) substitutes a more expensive drug which drives costs higher. He feels that the current generation of seniors are arguably the healthiest the world has ever seen, but somehow need twice as many medications. Why is that? Goldhill offers the following: explosion in the volume of services beyond what anyone ever predicted.

Facts True. Analogies and Conclusions Fall Short.

So Goldhill has identified many of the issues in health care. The trouble with his interview is though many of his statements were true, his underlying reasons and conclusions were not. His assumption – health care was given a pass by the public and the customer was insurers and the government – were his attempts to explain the current health care system. Unfortunately, this framework does not work on a number of levels.

Goldhill provides many analogies to Jha, but none of them work for health care. In many instances, he uses since situations which have a clearly defined task or job (dry cleaning, emergency flat tire on freeway) and its business solution (IT system implemention, price transparency / pressure) to compare and match with a health care situation (hospital with multiple venues – ED, inpatient, outpatient, radiology, and multiple tasks and specialties – xray, lab, clinical documentation; emergency department where people present with a problem, but where the workup process and treatment may vary widely depending on what the findings are) and health care’s inability to match businesses of other industries (no IT adoption without government regulation, no price transparency). The former examples are far more simplistic both conceptually and operationally than the latter. Let’s ignore the high degree of oversight and regulation as well, which does not exist in the former examples.

When Jha asked him whether health care might be different than other industries, Goldhill understandably does not think so. All other industries also claim to be different. That isn’t so, says Goldhill. He does not believe health care change difficulty is real or true. Yet Goldhill fails to come up with a good reason why the well-known 5 steps evangelized by Dr. Peter Pronovost, a national safety leader of John Hopkins, to decrease central line infections only has had uptake in 1,500 out of 5,000 hospitals. Even though the evidence has been very compelling and available for many years, many hospitals have been unable to do it routinely. The customers supposedly health care is serving, insurers, Medicare, and Medicaid, surely don’t want to pay more for prolonged hospital stays. What gives?

Jha wondered if asking patients to put more financial skin in the game might it be possible that they will skip preventive care which will be far more costly in the future? Goldhill conceded that it might be true. He recognizes that in fixing a complex system like health care there must be tradeoffs. This might be easier to accept for a businessman, but harder to accept for a doctor.

Certainly for decades, health care has behaved very differently than other industries. Is it simply because consumers have given it a pass? Might Goldhill’s framework and assumptions on why the system is not working well, wrong? He notes:

• “We’ve made a social choice. As a society we’re gonna spend less money on your wealth, less money on job creation, less money on diet, less money on the environment, less money on education, less money on lifestyle issues all the things by the way that we know that contribute to health and more money on health care.”

Outsider Status – Fresh Point of View Which Can Hit or Miss

Outsider status, like a business person looking at health care, has both pros and cons. By being on the outside, one may not have biases that may anchor those who are insiders. The downside, however, is not fully understanding the nuances and issues that exist. A far more comprehensive framework of both the ills and remedies for health care was provided by Professor Clayton Christensen of Harvard Business School and his book, The Innovator’s Prescription: A Disruptive Solution for Health Care.

When Goldhill talks about how computers in 1965 were limited to a few people and organizations (IBM, IRS, NASA) and were incredibly expensive and complex, and today are now inexpensive, available to all, and easy to use like the iPhone, Goldhill is describing disruptive innovation. This term was first coined by Christensen in his book The Innovator’s Dilemma. The subsequent innovation occurred after multiple iterations of various technologies. It wasn’t because consumers demanded better or didn’t give computers companies a “pass” and somehow when it came to health care, consumers missed the opportunity. Goldhill noted in his discussion that, “consumers are idiots” and that in any consumer driven industry, it isn’t that they research, but rather that the sellers or providers make it incredibly easy for consumers to access and purchase their goods and services.

So, a better framework might be – can disruption occur in health care? Yes, but it won’t be in every venue. Those symptoms and treatments which can be fixed to a protocol and a well defined job or task is identified, one would expect lower costs, more convenience, and improved access. Lasix eye surgery, retail clinics are good examples of defined tasks. However, medical science is not at the level where every constellation of symptoms or illness has a protocol. This is the costlier part of health care.

Could the business world, which Goldhill likes to tout and associate with as his outsider status, be the cause of the health care crisis? Goldhill does not even address this idea but yet the obesity epidemic is too prevalent to not be somehow a systemic or structural issue. Certainly there have been innovations and societal shift from agricultural to service oriented that have made us less physically active and may have contributed to the problem. What has been increasingly clear and far more worrisome, however, is that perhaps the unhealthy epidemic is due businesses, like the food industry, which have systematically developing habit forming foods, making billions on consumers by providing this “food”, and then washing their hands of any responsibility – (NY Times – The Extraordinary Science of Addictive Junk Food). If the government were so bold as to regulate these types of food the same way it did other public health hazards, what would the outcome be for those businesses and the health care system?

Goldhill may have a bias as an employer trying to save health care costs in his desire to restrict coverage to catastrophic care and drop more comprehensive coverage. I suspect it is his belief that since obesity is so prevalent that it is the “norm”, a lifestyle and therefore not a true medical problem. We (employers, businesses) should not be subsidizing bad habits or behaviors. But what if those businesses which wish to walk away are in fact the ones that caused the obesity problem in the first place? At the macro level, we as a society must ask if we find it acceptable that children born since 2000 will be the first generation not to live as long as their parents because of the prevalence of chronic diseases like diabetes. Their lifetime risk of diabetes is one in three. Their grandparents risk of diabetes age 65 now is one in four. Is Goldhill prepared to take on his business colleagues and ask – at what point to businesses not only have a profit motive but a societal one as well?

Who is the Right Customer?

Finally, he speaks about how health care does not speak to the right customer, the patient. In this remark, he is only partially correct. The right customer in fact is the patient-doctor unit or relationship. Each has a significant role to play to make health care better. Patients don’t order medications, imaging tests, or procedures. Doctors do. Whether doctors order the least expensive but equally as effective test is dependent not only on the doctor but also the patient.

Goldhill is correct that if doctors or patients are penalized financially to order a treatment that is no longer covered, then they will navigate to the more expensive option. As an example, patients like to have over the counter medications charged against their Health Savings Accounts. It turns out the IRS requires a physician to state that it is medically necessary. Given a duty to do no harm and since it is about the doctor-patient relationship, should a doctor write that a patient’s Claritin for allergies was medically necessary and should be covered? What if she says no? Where is the incentive to do the right thing here? Who benefits? It appears that any system, even one where patients have financial skin in the game, can result in less than desired outcomes.

Today and for the foreseeable future, doctors have an increasingly more important role and responsibility. We need to look out for our patients, hold ourselves accountable for not following Pronovost’s 5 step checklist for central lines, and ask ourselves critically whether we can do better. As doctors, we need to be like business leaders, adopt learnings from other businesses where they are applicable from process improvement via the Toyota Production Model (as done by Virginia Mason), implementation of information technology, a focus on service, quality, and safety as well as emulate other medical groups which are integrated, physician lead and physician run.

As doctors we need to lead change and fix health care.

Health care needs to be fixed. It isn’t clear, however, that Goldhill’s business plan is the one to do it.