Intermountain Healthcare -- Proof That U.S. Hospitals Can Improve

By John Ballard

I haven't read it yet but this is a snip from my next reading assignment. I'm posting as I wait for the printer to finish eleven pages.
H/T Maggie Mahar's blog. Looks like pretty good content.

Followup later: It's an excellent article. Recommended reading. Notes and comments after this snip...

VII.

ONE DAY, WHILE I was standing in Intermountain�s cardiology intensive-care unit, which, unlike those in many other hospitals, is next to the cardiac-surgery wing, it occurred to me that Intermountain really was not so unusual. It is unusual for a health care organization. But its story is fairly typical in the rest of the economy.

The executives at a company realize that their industry has built up all kinds of bad practices over the years. Those practices damage the quality of their product and waste money. The executives do a rigorous analysis of their operations, relying on solid information rather than conventional wisdom. And then they persuade their colleagues to make changes. Much of the lingo of management theory � �quality,� �lean,� �Six Sigma� � is simply a dressed-up way of describing this approach.

James peppers his classes with anecdotes about W. Edwards Deming, arguably the original quality guru, and it is easy to see why Deming would be attractive to James. Deming grew up on a farm in Iowa in the early 20th century and majored in electrical engineering at the University of Wyoming. During World War II, he was part of a committee that helped the government make wartime production more efficient. After the war, his statistical methods caught on in Japan, and the Japanese credit him with helping to make their postwar boom possible. The so-called Toyota way stems from Deming�s work. Eventually, the same ideas caught on at General Electric, Intel, Wal-Mart and elsewhere in this country.

But there is a fundamental difference between Toyota and Intermountain. As Toyota built better cars than its competition for less money, it won new customers. Some rivals matched its successes (as Honda did); some lost market share (as Detroit did). No such dynamic exists in health care. William Lewis, a former director of the McKinsey Global Institute who studies productivity, says that the economic benefits from the various quality movements have been quite large but that they are also largely in the past. Most industries have incorporated Deming�s big ideas and are now making only incremental progress. �However, there is one big exception,� Lewis adds. �You guessed it: health care.�

Why? In part, it is the faith that patients have in their doctors. When people are buying a car, they often consult Consumer Reports or Road & Track. When they are choosing a place to have surgery, they ask their doctor to recommend a surgeon and go to the hospital where that surgeon works. Hospitals that provide less than top-quality care are rarely punished in the way that General Motors and Ford have been.

Even more important than how we choose our health care, though, is how we pay for it. One of Deming�s principles is that improving quality also tends to reduce costs. That is not always the case in health care; expensive treatments � implantable cardiac defibrillators, for instance � can bring enormous benefits. But Deming�s principle holds more often than you might think. When in doubt about the best procedure, doctors tend to do more � more tests, more procedures, more surgery. So if a hospital does a rigorous analysis of what actually works, it is likely to discover a fair amount of waste.

But in our current health care system, there is no virtuous cycle of innovation, success and expansion. When Intermountain standardized lung care for premature babies, it not only cut the number who went on a ventilator by more than 75 percent; it also reduced costs by hundreds of thousands of dollars a year. Perversely, Intermountain�s revenues were reduced by even more. Altogether, Intermountain lost $329,000. Thanks to the fee-for-service system, the hospital had been making money off substandard care. And by improving care � by reducing the number of babies on ventilators � it lost money. As James tartly said, �We got screwed pretty badly on that.� The story is not all that unusual at Intermountain, either. That is why a hospital cannot do as Toyota did and squeeze its rivals by offering better, less-expensive care.

For all of its focus on efficiency, Intermountain, too, can be tempted by the dark side of the fee-for-service system. In one committee meeting, I listened to a debate about how much the hospital should charge patients for a certain medical device. Intermountain previously had negotiated a price reduction from the manufacturer that saved thousands of dollars on each device. But the hospital was still charging patients the old price, and the insurers, including Medicare, were still paying. That was what their reimbursement charts said they would pay.

A few people in the meeting were clearly bothered by this. They asked the finance executive, participating by speakerphone, if anything could be done. One committee member argued that Intermountain (which is nonprofit) should not overcharge for a treatment, even if it helped the hospital cover its overall expenses. The finance executive replied, apologetically, that changing the reimbursement rate would cost Intermountain millions of dollars and that there did not seem to be any way to make up for the loss. The meeting then moved on to another topic.

The excerpt above was grabbed at random to start a post, but it turns out to be a snapshot of the whole piece. The writer set out to advance the case for"evidence-based medicine" whereby better outcomes would result with closer collaboration from a team of physicians following better-understood "protocols" or "best practices." It seems straightforward, but on closer examination the practice of medicine really is just that, a practice. No one comes right out and says so in this article, but the reader is left with the impression that medical treatments can have improved outcomes at lower costs, but there is no Holy Grail which will supply all the right answers. In the end, for some cases an educated intuitive guess will often trump science and protocols.

...The human mind can store huge amounts of knowledge. Intuition is not simply belief; it springs from this knowledge. A doctor making an intuitive diagnosis is doing so on the basis of thousands of hours spent treating patients. The problem, however, is that the mind is not particularly good at sorting through this knowledge and weighing different parts appropriately. We give too much weight to information that confirms our suspicions or that is highly memorable.

Behavioral researchers have come to believe that there is a clear pattern to when intuition works and when it doesn�t. �Intuitive diagnosis is reliable when people have a lot of relevant feedback,� says Daniel Kahneman, a Nobel laureate in economics who recently collaborated on a project about intuition with Klein. People need a great deal of experience, and the feedback from these experiences � whether a treatment is working, say � needs to come quickly and to be clear. �But,� Kahneman adds, �people are very often willing to make intuitive diagnoses even when they�re very likely to be wrong.� When doctors have been asked to estimate the likelihood of a treatment succeeding based on experience, for example, they give wildly divergent answers. Medicine is full of such examples.

[...]

...Our fictional doctor heroes, from Marcus Welby to House, are iconoclasts who don�t go by the book. They rely on intuition, and intuition is indeed a powerful thing, be it in medicine or other parts of life.

Everyone has had the experience of being able to read someone�s face or voice � to know his or her mood � without knowing how. Then there are the stories of firefighters who have rushed out of a burning building shortly before it collapses. Gary Klein, a cognitive psychologist and researcher, collects examples like these, and one of the most powerful involves a paramedic who, at a family gathering, told her father-in-law that he needed to go the hospital. He said he felt fine. She prevailed on him. The next day, he was undergoing heart-bypass surgery. Like the firefighters and the face readers, the paramedic could not explain her reasoning. She did not know how she knew what she knew. When she was interviewed later, she said that she must have been tipped off by the kind of paleness and swelling that she had seen dozens of times before.

[...]

This debate between intuition and empiricism is as old as Plato, who thought that knowledge came from intuitive reasoning, and Aristotle, who preferred observation. The argument has seemed especially intense lately, as one field after another has struggled to define the role of human judgment in a data-saturated society. The police officials in New York City who overhauled crime fighting were classic empiricists. The debate over education reform revolves around how well teachers can be measured and what the consequences of those measurements should be. These disagreements can sometimes be exaggerated, because everyone agrees that intuition and empiricism both have a role to play. But the fight over how to balance the two is a real one.

Seeking a balance between science and intuition does not mean, however, that there is not plenty of room for both better outcomes and lower costs.The narrative is skillfully handled by David Leonhardt who wrote the piece. Dr. Brent James turns out to be the protagonist, but only because another prominent expert, Dr. Jerome Groopman, was not interviewed for the article.

TWO YEARS AGO, Jerome Groopman, the Harvard doctor and New Yorker writer, published a book called �How Doctors Think.� It would seem in many ways to be the kind of book that James and the other medical reformers would love. Groopman tells a series of stories about misdiagnosis and uses academic research, including Kahneman�s, to explain how intuition could lead doctors astray. But Groopman comes to a very different conclusion than the reformers do. In the book and his subsequent writings, he lays out the central challenge to what might be called the Intermountain way.

He argues that evidence-based medicine is useful in only a limited number of run-of-the-mill situations, like distinguishing between strep throat and a simple sore throat. �Human beings are not uniform in their biology,� wrote Groopman and Pamela Hartzband, a Harvard endocrinologist (and Groopman�s wife), in a Wall Street Journal op-ed article criticizing the Obama administration�s plans to tie Medicare payments to so-called quality metrics. �A disease with many effects on multiple organs, like diabetes, acts differently in different people.� Groopman and Hartzband mentioned a handful of studies in which protocols had led to outcomes that were no better, or even worse, than what doctors had previously been doing. A couple of the studies dealt with the regulation of blood sugar in diabetics, the same issue that came up in the primary-care meeting I attended at Intermountain.

To Groopman, a fundamental problem with �systems analysis,� as he calls it, is that it discourages doctors from considering a wide-enough array of possible treatments. He also worries that if doctors are judged based on how well they follow a protocol, they may follow it even when they are correctly skeptical of it. Groopman says that the proper solution to misdiagnosis instead lies with individual doctors. If they are taught the ways in which their instincts can lead them astray, and if they reflect on their previous mistakes, they can avoid some of the pitfalls of intuition. They can become more self-aware.

[...]

I asked James one day whether he had read Groopman�s criticisms, and he said yes. �Groopman�s right at one level,� James said. �You cannot write a protocol that perfectly fits any patient. Humans that come to us for care are just too variable.� James likes to say that the trained, expert mind of a physician is the most valuable resource in medicine. He adds that he is simply trying to focus that resource on the problems where it is most needed: those for which data does not have an answer.

But James then pulled out a graph that was sitting on his desk. It showed a steep fall in mortality after Intermountain put in place a heart-failure protocol. Among other things, doctors now automatically receive a beta-blocker prescription to sign, or not, as part of a patient�s discharge process. The changes appear to save about 450 lives a year. Graphs like that one, he said, are the reason he believes in evidence-based medicine. It must be done right � with hospitals monitoring outcomes at every step, quickly sharing that data with doctors and altering the guidelines as necessary � and James acknowledges it isn�t always done right. He is not defending protocols per se. He is defending measurement. �Don�t argue philosophy,� he told me. �Show me your mortality rates, and then I�ll believe you.�

Groopman declined to be interviewed for this article, but after talking with medical researchers and social scientists, I think there is a way to make sense of Groopman�s and James�s dueling narratives....

?000?

I remain convinced that health care reform has already begun, even before legislation has been formalized. Physicians, thankfully, have seen enough of science to know its limitations. And there is something humbling about the practice of medicine for even the most outsized egos. There will always be a place in the medical community for experts and specialists, but even in the rarified air of the surgery, the best of doctors know that their excellence rests on collaboration with their peers. That collaboration predates modern science and will always be an essential component of medicine. No amount of evidence, statistical or otherwise, will trump the judgment of a good doctor. If nothing else, this article is a case study underscoring that idea.