This Is Normal?

by Joe Flower

2000 words

International Copyright 1996 Joe Flower All Rights Reserved
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There are many practices considered normal in healthcare that would get you fired in other industries. If a hotel woke up each of its guests in the middle of the night to vacuum or fix the TV - the way many hospitals wake up the sick to perform routine functions - it would not last long. If any other business routinely kept its customers waiting a half an hour or an hour past appointment times, it would die a quick death. If an insurance agent, a stock broker, a real estate agent, or a consulting engineer withheld vital information from clients in the manner that is routine in healthcare, the resulting lawsuits would destroy them. If a legislator, a judge, or a regulator turned out to have a financial interest in the outcome of a decision with major importance in people's lives - as doctors routinely do when they order tests or recommend surgery - they would be brought to trial on criminal charges. If a restaurant jacked up the price of your meal because the guy two tables down had ordered pate and a magnum of Mumm's but had no money, you wouldn't pay it.

I called the main number of one of the country's largest and best-known major urban teaching hospitals, four times in four days, let the phone ring 25 times each time, and no one ever picked up the phone - not a machine, not a recorded message urging me to wait, just ringing. No one home. I finally reached my party by randomly dialing similar numbers until I reached someone in the hospital. I don't think that would happen if I dialed the main number of Paramount Communications, Chrysler, or Hormel.

One executive bragged to me that his hospital had halved the average waiting time in Emergency - to two hours. They were getting a lot of walk-in business on the rebound from the guy across the street, whose average wait was eight hours. Another system looked at the time it took an average patient to see a doctor after they arrived at Emergency. The spread, among all their hospitals, was 30 to 90 minutes. If the 90-minute sites could get their average down to 30 minutes, that would be a great accomplishment. But is 30 minutes good enough? This is average, counting all the cardiac arrests and shock victims who are seen instantly, so if you are not actually dying it's going to be far more than 30 minutes. Is 30 minutes a good average? Is two hours? I don't know the answer, but the people who run healthcare in America are just beginning to ask questions like these.

The health care industry is the weirdest industry imaginable. Think about these points:

We Americans have a passionate thing going with the health care industry. We distrust hospitals, despise insurance companies, and fear the intricacies of health care plans. We trade stories of doctors that charge $158 to re-wrap an Ace bandage, Emergency Departments with eight-hour waits, hospitals with all the nurturing warmth of an auto scrapyard. At the national and state level, we have debated (and for the most part, given up on) massive programs to fix the whole thing - programs attacked by some politicians, insurance companies and medical associations as radical and disastrous, and dismissed by many experts as bandaids on a cancer.

The good news is that experiments are being tried - and succeeding - across the country, experiments that point to a future of better, more humane, more universal healthcare for less money, attempts to invent an actual "health care system" that has the goal of keeping people healthy. The surprising result, demonstrated over and over, is that, with the right kind of attention, the bleeding-heart-liberal pay-for-everything position and the bottom-line cost-cutting hard-line position turn out to be the same position.

Some of the sounds of hope come from intensive studies of normal clinical practices. For instance, one hospital in Kalamazoo, Michigan, looked at its heart operations, and made changes that resulted in 34 percent fewer deaths and an average of two days less in the hospital for each patient - all for $4000 less per operation. A hospital in Cleveland combined its cardiology and cardiac rehabilitation departments and discovered that two thirds of the patients formerly scheduled for bypass operations don't even need them - if you give them some good, strong education and guidance in diet and exercise. This kind of scrutiny is called "clinical benchmarking," and it is just beginning to take hold in the industry.

Other kinds of benchmarking are having similar effects on other parts of the hospital. One group of hospitals in the Western states has set out to study an interesting question: Granted that hospitals are more complex than hotels - but if a pre-registered Marriot guest can just stroll up to her room and skip the registration desk entirely, why does it take two hours, 12 forms, and the assistance of eight people (on average) to get the same woman into a hospital bed?

Other efforts show that humanizing the hospital saves lives and money. The Planetree model, started in San Francisco and now working in six hospitals across the country, makes hospitals more homelike, respects patients' privacy, makes them partners in their own care, and engages their families in the process. This kind of thoughtful, respectful care might seem like an expensive frill, not medically important, available only to those who can afford to be pampered. But seven years of experience at San Francisco's Pacific Presbyterian have shown surprising results: Planetree care doesn't just feel good, it actually is cheaper - and it saves lives. The medical outcomes are better. Now, on the island of Hawaii, a new hospital is being built from the ground up around a similar set of ideas.

Over the past decade, the "Healthy Cities" model has spread through the World Health Organization to over 1000 cities worldwide, spurring local action to attack poverty; poor housing, water, and sewage treatment; environmental pollution; lack of education and myriad other factors that drag down the health of the population.

Within the United States, "integrated systems" of all types are growing like petri-dish amoebae, sucking hospitals, insurance groups, doctors, clinics, and home-health groups into confusingly vast entities. Yet these systems hold out an intriguing promise: when they become comprehensive enough, they can bid on providing total health care for a fixed fee to large population groups: unions, or employees of whole industries. The advantage is simple: these huge systems are not paid by the procedure, or even by the disease, or by the hospital admission. They are paid by the person. They are paid for what are called "covered lives." They have every incentive to keep their populations as healthy as possible. And the cheapest way to do that is to keep them from getting sick in the first place. For the first time in America, major organizations are being paid to keep people well.

Yet none of these experiments, and none of the defeated reforms, come close to the ideal system that we could build if we put our best minds to it. The experiments each address only a piece of what is a systemic problem. Price caps, managed care, and other legislated controls only distort the system. In the 1980s, for instance, when the government and insurance companies began defining diseases and setting the prices they would pay hospitals for each disease, "diagnosis creep" set in - diseases tended to get upgraded in complexity and seriousness to levels that paid better. And hospitals began to specialize in areas that were not defined, such as alcohol rehabilitation and weight loss. Systems tend to work to defeat simple legislated solutions.

In the 1994 healthcare debate in Congress, in the newspapers, and on talk shows, we seemed to know that we can't carry on the way we have, but we tended to lump our alternatives into a bag called "more government." We pictured a Soviet-style system in which we have no choices, wait in really huge lines, fill out vast forms and get treated like worms - all in the name of doubtful cost-cutting. The change has to start deeper, asking not just, "How do we pay for more people to get fixed?" or "How do we keep the costs down and increase the quality of medical care?" but "What is health? What does it mean in our lives? Where does it come from? How do we create it?"

These are far deeper and wider questions, and they lead us in the direction of community and family, of what we eat, how we deal with conflict, with problems of class, education, and true human economics - questions that we have to face if we are ever going to make a healthcare system that works.

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