US Healthcare: Greasy Spoon at Four Star Prices

Atul Gawande, a physician and writer, has published a piece in the New Yorker (August 13 & 20, 2012) about how the restaurant chain "The Cheesecake Factory" produces quality food at a reasonable price but more importantly how that model could be applied to health care delivery. Here are some quotes:

In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven't figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.

I (Atul Gawande) asked him (the son a woman with early Alzheimer's disease who manages several Cheesecake Factory restaurants) what he would do if he were the manager of a neurology unit or a cardiology clinic. "I don't know anything about medicine," he said. But when I pressed he thought for a moment, and said, "This is pretty obvious. I'm sure you already do it. But I'd study what the best people are doing, figure out how to standardize it, and then bring it to everyone to execute." This is not at all the normal way of doing thins in (American) medicine.

In (American) medicine, good ideas still take an appallingly long time to trickle down. Recently, the American Academy of Neurology and the American Headache Society released new guidelines for migraine-headache-treatment. They recommended treating severe migraine sufferers--who have ore than six attacks a month--with preventive medications and listed several drugs that markedly reduce the occurrence of attacks. The authors noted, however, that previous guidelines going back more than a decade had recommended such remedies, and doctors were still not providing them to more than two-thirds of patients. One study examined how long it took several major discoveries, such as the finding that the use of beta-blockers after a heart attack improves survival, to reach even half of Americans. The answer was, on average, more than fifteen years.

Yet it seems strange to pin our hopes (in health care) on chains. We have no guarantee that Big Medicine will serve the social good. Whatever the industry, an increase in size and control creates the conditions for monopoly, which could do the opposite of what we want: suppress innovation and drive up costs over time. In the past, certainly, health-care systems that pursued size and market power were better at raising prices than at lowering them. A new generation of medical leaders and institutions professes to have a different aim. But a lesson of the past century is that government can influence the behavior of big corporations, by requiring transparency about their performance and costs, and by enacting rules and limitations to protect the ordinary citizen. The federal government has broken up monopolies like Standard Oil and A.T.&T.; in some parts of the country, similar concerns could develop in health care.

The critical question is how soon. . .quality and cost control will be available to patients everywhere across the country. We've let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. The Cheesecake Factory model represents our best prospect for change.

My comment:

Atul Gawande has written some of the best commentary about American health care in the recent past. And this article is no exception, worth the time to read it.

Anyone who has recently had an encounter with American medicine is likely to know how inefficient and mediocre our health care delivery system is. And how appallingly expensive. If, as Gawande surmises, health system change begins to occur because the delivery system is reorganized into large 'chains' of clinical care facilities, there is a major risk which the analogy to restaurants does not anticipate. That risk is simple to understand: there will always be many restaurants in any town of size. But there can only be one hospital in at least half of the counties in the US. And limited numbers of hospitals in all but the largest cities. Health care is always subject to the problems of monopoly. And yet, many of the most expensive services (trauma care, perinatal care, organ transplants, burn units, open heart surgery) are demonstrably better when delivered by a sole provider in each catchment area. How to manage the threat of monopoly? As Gawande says, government is our only method for taming the behavior of large corporations. Health system reform will require the scaling up described by Gawande, but it will also require the organizing influence of the people as expressed through their government. But, traditionally, government influences on health care systems have been best achieved at the state level.

The Affordable Care Act, however, is emphasizing federal rules over local interests. And it is turning the notion of government influence on its head by essentially requiring governments to turn over tax money appropriated for health care to private for-profit organizations. The ensuing feeding frenzy is shredding the notion that government can shape the direction of health care policy.

Dr. Joe Jarvis