Gawande and the NYT – A way Forward

Dr. Atul Gawande (The Cost Conundrum, New Yorker Magazine, June 1st 2009) and New York Times (Editorial “Doctors and the Cost of Care”, June 14th 2009) provide very insightful, critical, and constructive commentary on what is potentially wrong with the US health care system. Primary reasons allude to overutilization that has created waste with questionable quality and impact.


In other words we have not had very good bang for the buck.

Dr. Gawande well known for his insightful essay’s and books on quality of health care points out through vivid testimonial accounts that there are vast discrepancies in health care costs within the US, even after taking into account differences such as severity of illness. Some of these discrepancies have been known for over the past decade. For example the work of Professor Don Berwick and colleagues is seminal. The Institute for Healthcare Improvement (IHI), since 1991 has highlighted how inefficiencies in health care cost billions of dollars and thousands of lives each year in the United States.

Looking closely at Dr. Gwande’s article there are several subtle hints that are made that point fingers towards the advent of ‘profit centers’ and ‘maximizing revenue’ practices for artificially driving up health care costs. These buzz words allude to how the ‘business’ of health care has created the ‘high cost’ and questionable quality of health care service. We need to ‘avoid looking at fragment quantity driven systems.”


Dr. Gwande further suggests that potential answers to the existing problem are to “reward doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, under treatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate.”


As compelling as this analysis is, these recommendations assume that a) maximizing revenues produces an inefficient health care system and b) large hospitals and physician groups will naturally induce incentives and goals to provide high quality health care while reducing costs.


While these are important assumptions, there are some other assumptions and questions worth highlighting.

1) While there is plenty of evidence that an unregulated fee for service system produces over utilization of health care resources, there is also evidence that maximizing revenues and promoting competition provides strong incentive to reduce overall operating costs.

In the US health care system the consumer (patient) does not typically assume the full cost of service. Thus the insurer (typically the government and ultimately the tax payer) may assume the brunt of these costs and while the patient may not be any worse off (though there is an alarming rate of medical errors, that could be caused by over utilization of services), we have a system that has differences in utilization of health care resources for questionable/debatable return. What is needed as Dr. Gwande suggests is cost effectiveness and delivery consortiums that will support national, state, and local level evaluations, best practice identification, and as needed operations research to examine cost, quality, and effectiveness of health services and procedures.

However, how much power the outputs will have over reducing health costs is to be seen. Ultimately unless there is a pay for performance/pay for quality incentives created for multiple stakeholders (patients, insurers, and doctors) these studies will have little influence on reducing overall costs in the US health care system.

2) Is there strong evidence to suggest that non-for profit health care systems reduce costs and promote higher quality any better than a for-profit model?

Currently, many of the higher cost and cutting edge technologies and procedures that are introduced into our system have originations from non-profit systems. The results of controlled clinical trials are typically written up in the most prestigious scientific journals and have influence on driving health care practice for millions of Americans. Concentrating the power of providing health care services into non-profit organizations and local communities to self regulate quality is not the full answer. Monopolies or oligopolies can drive up costs regardless of for profit or non-for profit structures. Thus, laws in various states have long safe guarded against collusion and price fixing.

To assume that physician or hospital groups will entirely focus on quality and reduce costs when faced with limited local market competition is not an entirely plausible outcome. This sort of self regulated market place has failed in the past. Just look at the recent wreckage of the financial sector to see the latest evidence of what relying heavily on self regulation can do. There needs to be a cost effectiveness and quality improvement mechanism that can positively influences what services are paid for based upon evidence/outcome.

3) What defines ‘high quality service?’

Quality to this day means many things to many people. Thus, there still is much debate regarding how to standardize quality for specific procedures. There needs to be more effort to establish minimum ‘quality’ standards for specific procedures. This may include mortality, morbidity, length of stay, quality of life, and patient satisfaction statistics. A significant challenge is that the large gap in knowledge and often paternalistic nature between the physician and patient. If a patient is facing a life threatening or terminal illness, how many families would argue with the doctor for less service and procedures?

4) Dr. Gwande’s article states no one teaches you how to think about money in medical school or residency? What about student debt?

There are estimates that the average debit of students upon completion of undergraduate college and medial school is over 200,000 USD. Having personally taught courses at Harvard Medical School the past 10 years, many students are shaped by the type of practice they go into because of the debt they are saddled with or the sincere desire to work with the most cutting edge and often expensive technological advances to save lives.

5) While utilization disparities are inherent in our system, a related factor is the impact of expensive medical technologies that drive up health care costs.

Without a strategic look at investment in health care technologies and services that promote preventive home based services and introduce lower cost devices and personalized medicines, the system will continue to spiral upwards.

6) Leadership, quantitative analyses to establish organizational control systems, quality of service, and maximizing customer satisfaction are tenets of good business practice.

These certainly can lend value to help improve quality and reduce unnecessary costs. Let us not forget that a significant problem that contributed to the high cost of health care has been the government’s reimbursement to providers that has used the fee for service model of service delivery. A former Professor of mine, William Kissick from the Leonard Davis Institute at the Wharton School used to compare this system to giving a credit card to your teenage son or daughter hitting puberty and saying spend as much as you want and do not worry about the tab. Essentially, we had supported the system with unlimited rocket fuel, without thinking much about the price of the ride.

7) Most physicians in general will do as much as they can to benefit their patients.

The majority of doctors want to do no harm, yet provide maximum service. Isn’t that the type of doctor we all want if we are sick? Who wants to hear, “you have a 10% chance of survival, there is an experimental therapy available, but sorry scientific studies have proven it is not very cost effective.” The fact that for-profit and non-for profit entities have learned to leverage the system to maximize revenues based upon these inherent principles of personal self interest to live as long and healthy life as possible should not surprise anyone. These principles have led to the discovery and usage of some of our most promising therapies.

8) Who speaks for the uninsured?

Our country has over 40 million unisured, over half are estimated to be children. Will reducing overutilization of services support coverage to the uninsured without shifting the incentives to do so? The answer is no. One way forward will be to form a public and private partnership to pool clients and provide basic health services as well as a reasonable safety net for those unemployed and looking for work.

Personal Reflection - Strengthening Health Systems

In Tanzania, I have had the privilege of working with the public and private sectors to develop strategic recommendations on how to improve patient care for infectious (HIV/AIDS, TB, and Malaria) and non-communicable diseases such as diabetes and heart disease. What is required to complete this activity is a detailed analysis of the entire health care value chain. This involves an understanding of factors and stakeholders that influence supply of demand health services that impact delivery.

Supply factors include; cost of medical education, clinician decision making, medical technologies, and public private partnerships, demand includes; patient driven demand, financing, as well as societal values and context for expecting health services. A common flaw in trying to assess a health system is isolating specific components without taking into account the entire value chain. Thus while overutilization of services make compelling news stories, these are symptoms of a more complex value change and production process that needs a closer examination.

The rising cost of health care has been an issue for over 40 years, especially since the establishment of Medicaid in 1965. The problems are not new. These include the introduction of live saving yet expensive medical technologies, limited cost effectiveness data for services/technologies/procedures, a focus on illness and not wellness/prevention, and inconsistencies as well as misalignments between the demand (patients), payment (insurers), and supply (physicians) for health service delivery.

What is required is a national, yet decentralized office for health care quality/delivery improvement tasked to develop a series of pilot initiatives that examine current best practices and support new practice models across the value chain. These would include both short term and longer term evaluations. We cannot afford to wait ten years for longitudinal results before taking action. Some evaluations could also be performed using simulations and forecasting models that use existing evidence for specific components of the health care value chain. S

Evaluations might include 1) bulk purchasing of primary care services for the uninsured to reduce overutilization of emergency room visits, 2) opinion survey’s regarding affects of reducing the cost of medical education on young MD decision making, 3) providing quality reports directly to consumers to help make difficult decisions regarding expensive/low yield procedures, 4) create research and development incentives for low cost diagnostic technologies to replace high cost/high margin services, 5) reimbursement models that use pay for quality report cards. These can all be evaluated to determine areas for savings in costs and while either maintaining or possibly improving health services.

Asante Sana Dr. Gawande for your insight and commentary.

Why the world and America needs Paul Farmer

I remember very clearly in March 2004 arriving into Kingston Jamaica. I was just tapped to be a Volunteer Country Director for the Clinton Foundation. The task was to work closely with a team of clinicians, business personnel, and ministry officials to help finalize the HIV/AIDS treatment and scale up country proposal for the Global Fund.

I remember during the first week on the job driving past a local prison. Our guide described the prison as a place where only ‘The Lord” smiles upon. It was known as a place where HIV/AIDS was rampant from drug use and unsafe sexual practice. However, for a variety of reasons was a population where no one cared to provide access to treatment.

It seems everyone has an opinion about Dr. Paul Farmer. The Far right question America’s role and tax payer dollars to help in the fight against poverty and strengthening health care abroad with over 40 million uninsured in America. The left promote Dr. Farmer as the world’s ambassador against poverty and disease. But without question, quite simply, Dr. Farmer has dared to go to those places where only ‘The Lord” smiles upon.

Paul (Dr. Farmer prefers both strangers, myself included in this first category, and close colleagues to avoid formal titles) has dedicated his life to improving the lives of those forgotten in the global economy. Regardless of whether you support his work, one cannot deny him full respect and admiration. He will be the first to admit he is not someone to be worshiped. Just a doer, who loves to do. Through his actions and doing, Paul and Partners in Health have directly impacted the lives of millions around the globe.

The world is a much better and enlightened place because of Paul and his ability to inspire many to think less about themselves and more about how they can help others.

Currently the Obama administration is working to convince Paul that he should become their global health ambassador. If this ultimately becomes reality, let us all be thankful. Because not withstanding the inevitable political minefields that await and budget battles to be fought, Paul will assuredly exponentially raise America’s stature in the world as a serious advocate for human rights, poverty reduction, and global health.

Happy Mothers day and Reflection

We wish you a very happy, wonderful, and happy mothers day.

Appropriately Mr. Nicholas Kristof from the NYT has given us a gift of reporting on a condition that effects both mothers and children, yet remains largely under funded with few direct advocates. Mr. Kristof reports that childhood pneumonia is an illness that is easy to treat, yet more than two million children die each year in developing countries. Thanks again to the herculean advocacy efforts of Lance Laifer the world is becoming better acquainted with a condition that Mr. Kristof states will kill almost twenty children in the five minutes it will take to read his column or my blog.

Though we are reminded that part of the challenge of advocating for childhood pneumonia is typically the condition can be a secondary infection caused by a primary underlying condition such as upper respiratory disease, HIV, malaria and malnutrition. Actually many scientists and health officials will argue that malnutrition or under nutrition and health illiteracy by parents are the biggest root causes of disease.

This highlights the challenge of advocating for a disease versus channeling the energy and funding dollars to strengthen health systems and increase health literacy to improve primary health care services and tackle root causes of disease. Otherwise, if we target a specific disease, yet do not thoughtfully look to apply needed attention to strengthen the health delivery system, we may get a disproportionate investment in treating one disease versus improving overall health services for mothers and children.

For example I’ve worked with local health workers in Tanzania to help develop primary prevention programs to eradicate rheumatic heart disease (RHD) over the last 5 years. RHD is thought to be an entirely treatable and preventable condition (it was a leading primary and secondary cause of cardiovascular death in the US prior to the discovery of penicillin), yet we have millions of children and adults in the developing world suffering from this disease. However, my colleagues and I have learned that the root cause and treatment for RHD goes beyond screening for streptococcus A and handing out penicillin. The inability to eradicate RHD in the developing world also has also been effected by traditional focusing on disease specific programs versus strategic strengthening of systems to detect and prevent diseases among infants and children.

Lance and Bill; We know your reporting and advocacy work are making an amazing difference for mothers and children the world over. The world needs more people like you bringing attention to these conditions. Lets hope that the tremendous advocacy and resulting funding dollars are spent wisely to also focus on root causes of disease and strengthening primary care and prevention services. Otherwise, the world will continue to follow the treatment of one disease at a time strategy versus creating a system that promotes wellness and health for an entire community and village.

Happy Mothers Day to all!

Beware of the Elephants – Common Sense guide for International Social Impact Field Projects

In the last several years there has been an exponential increase in the number of graduate and undergraduate students working on social impact projects in developing country settings. Many of these programs are short term engagements that last between 2 – 8 weeks over winter, spring, or summer intersession. Often times many of these students have never traveled to the destination site and are unaccustomed to the local cultural differences. While setting up a field program, a successful project is best driven by an experience field based mentor and supervisor. However the following are some tips for the traveling student to avoid unnecessary delays or impediments to having a successful experience:

Do not be a hero

If in an area that is endemic for malaria, TB, or other infectious diseases, do not hesitate to contact a local health worker or go to the nearest health clinic. Delaying care by a few hours can cause serious consequences. Before leaving for your destination make sure you have some form of international health insurance plan such as iSOS. Also, it is very important to remember to continue taking your malaria prophylaxis medications after your return from your destination as indicated by your prescription.

Your time is short, you can never plan enough

Do your best to gather as much information as possible to understand the context of the local problem and key stakeholders on the ground. Try in advance to schedule site visits and interview schedules before your arrival date. Be absolutely sure you have all the appropriate permissions and authorizations to collect and publish results.

Expected the unexpected, be flexible

The reality on the ground in global health is that most staff from junior to senior clinicians and administrators are over worked and have little extra time for new projects, regardless of the priority or importance. Often times an unexpected situation may occur. This might be work related – critical care emergency, or act of nature – heavy rains, flooding, or infrastructure related –email is not available, massive traffic congestion. Try to remain calm and work within the system. Use your mobile phone and SMS in advance to confirm appointments and maintain follow-up. Do not rely upon email as a primary tool for communication. Always have a back up plan.

Humility is critical

Too often I have see students intentional or not discussing details about an upcoming safari or upcoming job offers including salaries from summer internship positions. Remember in most instances one is working in an environment where there are vast structural differences and limitations to both educational and employment opportunities. Be appropriate and think before speaking. Remember that most of the professionals you are working with are mostly constrained by context, not by intellectual capacity or desire for advancement. If local partners sense you are insincere or in-country for a resume building exercise then the chances of accomplishing your goals for your project will be greatly limited.

Be smart, use common sense

When in doubt, don’t do it. Things that are most common that cause serious illness or worse include: 1) Eating or drinking from unsafe sources of water or uncooked food, 2) Traffic accidents. If the care or transport looks unsafe or the driver seems incapacitated due to alcohol or something else, just say NO!. It is better to be late than the alternative. 3) Unsafe pursuits. Most places of travel are endemic for HIV/AIDS. Unprotected sexual activity is playing Russian roulette. Also do not rely upon local safety standards for national parks and extreme sport activities. Double check all rented equipment, terrain vehicles as well as arrange activities through a recommended local travel agent. Saving money by seeking out unverified deals can cost you dearly beyond a hit to your savings account.

Create a weekly reporting system with interim and final deliverables

As described under the ‘humility section’ most officials you will be working with on the ground are extremely busy. Also chances are that most principle investigators or faculty members from your home institution will also be very busy with many other responsibilities. Manage both yourself and your ‘boss’. Prepare in advance meeting agendas that outline critical issues as well as a weekly summary of accomplishments, upcoming activities, and challenges or bottlenecks for action. Unless you carefully document your experiences and communicate effectively and concisely both accomplishments and challenges on a weekly basis, chances are that when your stay is over and you will have missed accomplishing many important milestones.

Health Communications 101 Part Deux: Swine Flu - Separating evidence from the fear factor.

Not sure about you, but I’ve been a little bit on edge recently with all the announcements of swine flu and media sound bites using outbreak, epidemic, and pandemic. Over the last few days there has been a wide range of news coverage of the Swine flu outbreak. Responsible coverage has provided factual information regarding what is influenza and has distinguished between pandemic and seasonal (non-pandemic) flu. I would also consider part of responsible journalism to include a discussion on why in 2009 the United States and the global community is better prepared to cope with an influenza pandemic than at any time in modern history. This includes wide availability of antibiotics that are used to treat secondary infections caused by the flu virus. What can be deemed as less-responsible journalism, has unnecessarily stoked fears of a Stephen King, “The Stand”, super bug, without a scientific review of facts and safeguards in place to avoid such a scenario.

The CDC has a Q&A regarding flu. For example did you know that it is estimated that over 36,000 Americas die each year from seasonal (non-pandemic) flu? However, it is acknowledge these statistics are somewhat inaccurate and possibly under reported for several reasons: a) it is not required to be documented for persons older than 18 years of age, b) the life of the virus is short, thus detection of the virus of a primary cause of illness is not always possible, and c) many persons who many die from flu like symptoms or secondary complications are never tested for the virus.

A scientific peer reviewed article by Peter Doshi (May, 2008) in the American Journal of Public Health provides a critical review of mortality related deaths due to pandemic and non-pandemic influenza since 1900. The article provides an assessment of the topic and concludes with a section entitled “Explaining the Gap Between Evidence and fear.” Due to copy write restrictions I am prohibited from posting excerpts from the article. However it is available through Medline or other online full text journal portals at your local library for individual use.

What we have seen in recent days is an alarm over a possible pandemic. But let us not forget that due to advances in health care infrastructure and modern medicine we are better equipped to handle such responses to ensure that the public is well protected. While there are still many gaps in our public health infrastructure, lets us also be confident and not cause undue panic before we have all the appropriate facts and evidence. Precaution is good. Wash your hands frequently, especially when in public places. If prone to upper respiratory infections, especially the young or elderly, consult a doctor if you may have symptoms of the flu.

In closing, an area that is of great need is strengthening our public health infrastructure in the United States to include the uninsured. In the United States, it is estimated in a recent institute of medicine (IOM) report on the uninsured that over 45 persons are without insurance. Thus for any minor or potentially significant health aliment these persons will most likely seek care and treatment at the local emergency room. In times when a flu pandemic is feared, the weaknesses of our public health infrastructure are most exposed. This will surely translate into unnecessary costs associated with inappropriate care and treatment at emergency rooms that could have been better served in a community health clinic.