During a June 22 general session at AHIP 2012, author Malcolm Gladwell espoused that the health care industry, unlike virtually every other industry, has not been able to eliminate the “chauffeur” in the care system, to the financial and clinical detriment of the country.

Gladwell, who penned Blink and The Tipping Point, among other books, opened with the trajectory of chauffeurs during the advent of the automobile. When cars first came to market, chauffeurs were critical for the rich because chauffeurs, unlike coachmen, understood and were responsible for the operation of a  complex new technology that was a mystery to others. They used that leverage to earn much higher wages than coachmen, as well as higher status in the social hierarchy. But as cars became commoditized, more reliable and less complex to operate, chauffeurs quickly lost that status as the wealthy began to drive their own cars—that is, the customer assumed control.

In every industry where disruptive technology has been introduced, Gladwell said, there has been an temporary need for a “chauffeer”—typically for 10 years or so after it was introduced--before commoditization and the consumer economy took hold.

But in health care, “the chauffeur never went away,” Gladwell said. As an example, he cited dialysis treatment; while the technology has been on the market for 70 years, the way dialysis is administered—with clinicians and technicians involved—has not changed. But in a study in Sweden, dialysis patients were given the opportunity to self-administer their dialysis treatments, which cut the costs by 50 percent and significantly increased patient engagement and adherence to their dialysis regimens.

“Commoditization and consumer control has never really hit health care, which makes it unique,” Gladwell said. “That may be due in part to the fact that disruptive technologies at first require trade-offs: the technology may be cheaper or easier to use, but it doesn’t work as well. Take digital music, for example: the sound quality of what our kids’ are listening to is vastly inferior to the CDs and records we listened to, but digital music provides much more freedom for the user to mix up sounds, carry it on a small device, etc. New medical diagnostic tools and patient self-service like dialysis could cut huge costs out of the system, but the threat of lawsuits and the initial discomfort of patients, among other reasons, have made the health care industry hesitate eliminating the chauffeur.”

Gladwell was followed by Atul Gawande, M.D., a Harvard professor and author of The Checklist Manifesto and Complications, whose first words were that he completely disagreed with Gladwell. The real problem with the health care industry is that it continues to seek the best and most expensive components of care—such as drugs and diagnostic tools—yet has spent very little time thinking about how those components and clinical services fit together. “Engineers will tell you that’s an impossible way to design—it’s like taking Porsche brakes and a BMW engine and the other ‘best’ components and trying to make a car. It doesn’t work because no thought is given to how the pieces fit together to make a whole.”

Technology innovation has been put to good use by the health care industry—as least until the past decade. Gawande showed charts tracing health care costs and mortality since the late 1800s. Prior to the 1940s, health care was cheap, but mortality stayed consistently high. After that, and especially during the 1960s, when Medicare, Medicaid and commercial insurance took off, costs rose, but mortality decreased. However, over the past decade, costs have soared, yet mortality has been unchanged.
 “The problem with rising costs is that there’s no apparent value,” Gawande said. “My research finds that the most expensive services do not yield the best outcomes, and that the facilities that have systematic care environments where treatments and services are slotted together consistently have the best clinical results.”

Gawande said his mother recently spent three nights in the hospital following a knee surgery, and had a total of 63 people involved in her care, including 19 physicians who wrote separate orders. Nowadays, he said, everyone is a specialist, and all the treatment “pieces” they’re providing are uncoordinated and isolated—and we’re paying fees for all those services.

What’s needed, he said, is a “pit crew” approach by clinicians, not patient self-service and commoditization. His example of how that works best is the new approach used on the battlefields of Afghanistan and Iraq. The military has created forward surgical teams in six Humvees that can set up surgical units within an hour. The teams lack X-ray equipment and find fractures by hand, and have to use a variety of other old school medical practices. But the clinical teams have systems to do field operations and other services and transport soldiers to acute care facilities quickly—at this point, they can have patients state-side in 36 hours. The mortality rate in Afghanistan and Iraq is 10 percent, which is dramatically lower—less than half the rate in Vietnam or the first Gulf War—than in any other war in U.S. history. And from a cost perspective, the efficiency has enabled the military to close hospitals and dramatically cut other costs, with some of the savings being used to invest in transportation services, Gawande added.


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