quality: an imperative for organizational survival · ethanol (and other recreational drugs) mdd...
TRANSCRIPT
Quality: An Imperative forOrganizational Survival
Brent C. James, M.D., M.Stat.Executive Director, Institute for Health Care Delivery ResearchIntermountain HealthcareSalt Lake City, Utah, USA
University of Texas System Clinical Safety & Effectiveness Building the Bridge at the Quality Chasm
Renaissance Hotel, Austin, TexasFriday, 16 October 2009 -- 7:15a - 8:45a
Disclosures
The content of this presentation does not relate to any product of a commercial entity; therefore, I have no ethical conflicts or relationships to report. I have no financial relationships beyond my employment at Intermountain Healthcare.
The roots of reform ...
Part 1
46 million people without health insurancecost increases that are bankrupting the country
Total health: How long, how well we live
~40%Behavior: Tobacco
Ethanol (and other recreational drugs)MDD (movement deficit disorder - obesity)Sexually-transmitted disease (AIDS)Unwed teenage pregnancySuicide, violence, & accidents (young men)
McGinnis JM & Foege WH. Actual causes of death in the United States. JAMA 1993; 270(18):2207-12 (Nov 10).McGinnis JM, Williams-Russo P, & Knickman JR. The case for more active policy attention to health promotion.
Health Affairs 2002; 21(2):78-93 (Mar).
Genetics~30%
Environment / public health~20%
Health care delivery (hospitals and clinics)~10%
The Great Equation:
Health = medical care
"But the Great Equation is wrong ..."
Aaron Wildavsky. Doing better and feeling worse: the political pathology of health policy. Doing Better and Feeling Worse: Health in the United States, John H. Knowles, ed. New York: W.W. Norton & Co., 1977.
and medical care = "access to care"
Health spending
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
0
5
10
15
20
25
% G
ross
Dom
estic
Pro
duct
0
5
10
15
20
Tota
l $ p
er U
S ci
tizen
(tho
usan
ds)
2,281
4,729
3,762
6,683
9,173
12,357
148 357 1,106
$906
$1,040
$2,376
$0 $500 $1,000 $1,500 $2,000 $2,500
Source: Kaiser Family Foundation, Wall Street Journal, 22Feb06
Healthcare - or a house?
Insurance premium - family coverage at
national average rate
Mortgage paymenton national median-value
($211,000) home
Health care delivery burden fora typical family of 4 when
insurance-funded and tax-funded care are combined
NoncitizensEligible but not enrolledTemporarily uninsured (job change)
Free riders (income > $84,000)
Long-term uninsured
9.5 million (~20.7%)
12 million (~26.1%)
9 million (~19.6%)
7 million (~15.2%)
8 million (~17.4%)
The uninsured - who are they?
Source: Rep. Lamar Smith, Christian Science Monitor, 16Aug09
1960 1965 1970 1975 1980 1985 1990 1995 2000$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
U.S
. Dol
lars
(tho
usan
ds)
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
United StatesCanada
Sweden United Kingdom Germany
Health cost per resident, by country
1960
1965
1970
1975
1980
1985
1990
1995
1996
1997
1998
1999
2000
2001
2002
Birth Year
65
70
75
80
85
Year
s ex
pect
ed li
fe
65
70
75
80
85United States Sweden United Kingdom Germany
Life expectancy at birth, by country
1960 1965 1970 1975 1980 1985 1990 1995 20000
5
10
15
20
25
30
35
# de
aths
per
100
,000
birt
hs
0
5
10
15
20
25
30
35
United StatesCanada
Sweden United Kingdom Germany
Infant mortality per 100,000 births
What do we get for all that money?
1. Total health -- how long and how well we live
2. High touch -- patients value their relationship with a trusted clinical advisor more than any other element in health care delivery (the clinician-patient relationship)
W. Edwards Deming: Aim defines the system ...Three possible aims of a health care delivery system:
A man stricken with disease today is assaulted by the same fears and finds himself searching for the same helping hand as his ancestors did five or ten thousand years ago. He has been told about the clever tools of modern medicine and somewhat vaguely, he expects that by-and-by he will profit by them, but in his hour of trial his desperate want is for someone who is personally committed to him, who has taken up his cause, and who is willing to go to trouble for him.
D. Emerick Szilagyi, MD: In Defense of the Art of Medicine, 1965(with thanks to Dr. Steven Kappes, Milwaukee, WI)
High touch: Caring, not just curing
High touch? Maybe not ...
1. Total health -- how long and how well we live
2. High touch -- patients value their relationship with a trusted clinical advisor more than any other element in health care delivery (the clinician-patient relationship)
W. Edwards Deming: Aim defines the system ...Three possible aims of a health care delivery system:
3. Rescue care -- the Rule of Rescue
Primary care vs. Secondary care
Rapid response: The Rule of Rescue
subconcious personal identification at an emotional level;a person instead of just a number; "a name and a face"
The child down the wellThe whales trapped in the iceThe dog on the abandoned boat"60 Minutes" program on pertussis vaccination
Joseph Stalin (who killed more than 17 million of his own Russian people)"A single death is a tragedy, a million deaths is a statistic."
Jonsen AR, 1986: The imperative people feel to rescue identifiable individuals facing (avoidable?) suffering or death.*
* McKie J & Richardson J. The rule of rescue. Soc Sci Med 2003; 56(12):2407-19 (June). Richardson J & McKie J. Working Paper 112: The Rule of Rescue. West Heidelberg, Victoria, Australia: The Centre
for Health Program Evaluation; 2000.
14.3
8.1
17.1
9.2
16.5
9.48.2
6.5
Major trauma Heart attack0
5
10
15
20
Mor
talit
y R
ate
(%)
0
5
10
15
20United States Germany Great Britain France
System performance, by nation
16.4
24.5
22.421.1
12.2
Neonates < 1500 grams
0
5
10
15
20
25
30
Mor
talit
y R
ate
(%)
0
5
10
15
20
25
30
U.S. Canada Germany Sweden U.K.
System performance, by nation
1970 1975 1980 1985 1990 1995 20000
20
40
60
80
100
# pa
tient
s on
dia
lysi
s pe
r 100
,000
pop
ulat
ion
0
20
40
60
80
100United StatesCanada
Sweden United Kingdom Germany
Renal dialysis per 100,000
1996 1998 2000 20020
0.5
1
1.5
2
2.5
# li
ver t
rans
plan
ts p
er 1
00,0
00 p
opul
atio
n
0
0.5
1
1.5
2
2.5
United StatesCanada
Sweden United Kingdom Germany
Liver transplants per 100,000
1996 1998 2000 20020
1
2
3
4
5
6
# ki
dney
tran
spla
nts
per 1
00,0
00 p
opul
atio
n
0
1
2
3
4
5
6
United StatesCanada
Sweden United Kingdom Germany
Kidney transplants per 100,000
115
75
81
88
88
92
97
97
106
107
109
109
129
130
132
FranceJapan
SwedenAustralia
CanadaNorway
NetherlandsGermany
AustriaNew Zealand
DenmarkU.S.
IrelandU.K.
Portugal
0 20 40 60 80 100 120 140
0 20 40 60 80 100 120 140
Deaths per 100,000 population
Mortality amenable to health care
Source: World Health Organization, Nolte and McKee, Rutgers Center for State Health Policy Standardized for age (1998)Utah from 2003, normalized for general US change from 1998
On a macro basis, many countries out-perform the U.S.:This is primarily attributable to healthier behaviors, better public health, and a heavy emphasis on easily accessible primary care (easy access = "high touch" = better satisfaction; primary care is relatively cost effective)
the U.S. system performs significantly better for those with severe illness or injury. This is due to several factors:
- Better access to technology- Less explicit and implicit rationing- Easy access to subspecialists - better / more extensive health professional
training; very much less waiting in line for specialty care (queueing)
International health comparisons
Current care deliveryoffers opportunities ...
Part 2
1. Well-documented, massive, variation in practices (beyond the level where it is even remotely possible that all patients are receiving good care)
2. High rates of inappropriate care
3. Unacceptable rates of preventable care- associated patient injury and death
4. A striking inability to "do what we know works"
5. Huge amounts of waste and spiraling prices, that limit access (46.6 million uninsured Americans, and still climbing)
Care falls short of its theoretic potential
50+% of all resource expenditures in hospitals is
quality-associated waste:recovering from preventable foul-upsbuilding unusable productsproviding unnecessary treatmentssimple inefficiency
Andersen, C. 1991James BC et al., 2006
Explicit liabilitiesPublicly held debt (e.g., the national debt)
Military & civilian pensions & retiree healthOther
$ 4.33.1
1.7
$ 9.1
Commitments & contingencies 0.9(e.g., PBGC, undelivered orders)
Implicit exposures
Obligations in excess of trust fundDebt held by the trust fund
4.0 1.7
Future Social Security benefits 5.7
Obligations in excess of trust fundDebt held by the trust fund
8.6 0.3
Future Medicare Part A benefits 8.8
Medicare Part B benefits 12.4Medicare Part D benefits 8.7
Total: $45.6 trillion
Note: Estimates for Social Security and Medicare are the intermediate 75-year estimates of the Social Security and Medicare Trustees as of January 1, 2005.All other data are as of September 30, 2004. Totals may not add due to rounding.Source: 2004 Financial Report of the U.S. Government and 2005 Social Security and Medicare Trustees reports.
U.S. fiscal exposures (Comptroller General David Walker)
trillion
Another way to think about it
Debt held by the public $4.3 trillionTrust fund debt 3.1 Gross debt 1 $7.4 trillion
Gross debt per person: about $25,000
The $46 trillion is fiscal exposures is:a burden of more than $150,000 per person or more than
$370,000 per full-time worker;nearly 19 times the current annual federal budget, and
4 times the current annual Gross Domestic Product;almost equal to the (estimated) $48.5 trillion total net worth,
including home equity, of all U.S. citizens.
1 Includes all debt held by government accounts.
1. Massively raise taxes (mandatory health insurance; increased Medicare copays and deductibles; fees on pharma, device makers, care providers, insurers, etc., passed along to patients)
2. Decrease benefits (e.g., means test Medicare; tighten coverage criteria for specific interventions)
3. Shift money from other areas in the federal budget
4. Shift responsibility to States(bait and switch through block grants)
5. Decrease payments to care providers
Funding federal health care
2022
19
7
32
27
21
9
13
30
46
14
0
7
33
DefenseSocial Security
Medicare / MedicaidNet interest
All other0
10
20
30
40
50
% o
f tot
al fe
dera
l bud
get
0
10
20
30
40
50
1964 1984 2004
Composition of federal spending
Source: Office of Management and Budget
Looming financial crisis
Unsupportable increases in federal spending
Employers exiting health insurance(and transferring cost increases to employees)
Increasing numbers of under- and uninsured
Medical tourism (off-shore treatment)
Specialty: measuring practice variation Observation: ~30% of all health expenditures happen in the terminal episode of life
Question 1: Is there variation in end-of-life spending?(Studies directly adjust for age, gender, ethnicity, burden of comorbid illness)
Answer 1: ~5X variation - $12,000 (Intermountain) to $58,000 (UCLA)Question 2: Is end-of-life spending variation associated
with spending levels before the terminal episode?Answer 2: Yes - >90% correlation 2 years prior, 5 years priorQuestion 3: Is end-of-life spending associated with quality
of care? (2 major studies - 1st examined mortality rates, 2nd looked at blended CMS quality measures)
Answer 3: Yes (consistent, strong, results from both studies)
Unfortunately, the relationship is negative:More spending = lower quality of care (by either measure)
Dartmouth CECS group (Jack Wennberg, Elliott Fisher, et al.)
Baicker, K and Chandra, A. Medicare spending, the physician workforce, beneficiaries' quality of care. Health Affairs Web Exclusive 7 April 2004; W4-184-97.
Medicare cost versus quality
We know why ...
Part 3
(1) Continued reliance on the "craft of medicine" (clinicians as stand-alone experts)
runs up against
(2) Clinical uncertainty
in the context of
(3) Payment that encourages utilization
Why? The collision of 2 forces:
The craft of medicine (each physician an expert)
placing her patient's health care needs before any other end or goal,
An individual physician
drawing on extensive clinical knowledge gained through formal education and experience
Can crafta unique diagnostic and treatment regimen
customized for that particular patient.
This approach will produce the best result possible for each patient.
Medicine's promise:
Clinical uncertainty (a hundred years of science)
Enthusiam for unproven methods ... Mark Chassin, MD
The maxim, "If it might work, try it" ... David Eddy, MD, PhD
Quality means "spare no expense" ... Brent James, MD, MStat
1. Lack of valid clinical knowledge regarding best treatment(poor evidence)
2. Exponentially increasing new medical knowledge(doubling time has decreased to ~8 years; at current rates, a clinician will need to learn, unlearn, then relearn half of their medical knowledge base 5 times during a typical career)
3. Continued reliance on subjective judgment (subjective recallis dominated by anecdotes, and notoriously poor when estimating results across groups or over time)
4. Limitations of the expert mind when making complex decisionsMiller, 1956: The magic number 7, plus or minus 2: some limits on our capacity for processing informationEddy: "The complexity of modern medicine exceeds the capacity of the unaided human mind"
Which, combined with the craft of medicine, leads to:
We have found proven solutions ...
Part 4
We have found proven solutionsShared baselines (a form of Lean Production) -
A multidisciplinary team of health professionals:1. Select a high priority care process2. Generate an evidence-based "best practice" guideline3. Blend the guideline into the flow of clinical work
staffingtrainingsuppliesphysical layouteducational materialsmeasurement / information flow
4. Use the guideline as a shared baseline, with clinicians free to vary based on individual patient needs
5. Measure, learn from, and (over time) eliminate variation arising from professionals; retain variation arising from patients ("mass customization")
Practical limitations on protocol use
When abstract guidelines hit real patient care, experience clearly shows that
protocol fits every patient;No
protocolNo fits any patient.(perfectly)
(with very rare exceptions)
more important,
Methods to manage complexity
Subspecialize (analytic method; reductionism; 'divide and conquer') (old joke: Know more and more about less and less until
you know everything about nothing)
Mass customize (a shared baseline: focus on that relatively small subset of factors that are unique by and for each individual patient [typically 5-15%], concentrating your most important resource -- the trained human mind -- where it can have the greatest impact)
6.66
3.36
2.47 2.65
3.44
4.26
37 38 39 40 41 42
Weeks gestation
0
2
4
6
8
10
Perc
ent N
ICU
adm
issi
ons
0
2
4
6
8
10
Deliveries w/o Complications, 2002 - 2003
8,001 18,988 33,185 19,601 4,505 258n =
NICU admits by weeks gestation
Elective inductions < 39 weeks
5.55.1
6.66.3 65.3
8.2
5.45.76.66.6
7.9
6.4
7.67.6
4.63.5
4.54.3
6.5
3.22.62.3
4.2
2.13.23.4
2.4
5
33.5
26.726.9
2929.2
25.3
27.6
20.4
19.1
16.5
15.2
8.4
10.7
8.1
6.85.96.1 6
5.1
6.3
Jan 01 MarMay Ju
lSep Nov
Jan 02 MarMay Ju
l
Jan 03 MarMay Ju
lSep Nov
Jan 04 MarMay Ju
lSep Nov
Jan 05 MarMay Ju
l
0
5
10
15
20
25
30
% e
lect
ive
indu
ctio
ns <
39
wee
ks
0
5
10
15
20
25
30
382372
490415
430435
422455
430382
356337
372366
455n = 423453
473476 512
475602
557667
564637
578541
573533
505501
474536
562545
535493
520494
430440
500421
474562
549555
528491
3331.4
36.1
28.3
17.7
15.1
17.6
14.4 14.3
5.84.5
2.1
0
20
8.2 8.5
3.6 3.4 3.9 3.22.4
1.1 0.9 10 0
1 2 3 4 5 6 7 8 9 10 11 12 13
Bishop score
0
5
10
15
20
25
30
35
40
Perc
ent c
-sec
tions
0
5
10
15
20
25
30
35
40
Unplanned c-section ratesElectively induced patients by Bishop score, Jan 2002 - Aug 2003
10 49 130 274 567 856 1114 1266 1062 737 415 86 1918 35 61 99 164 278 375 487 453 346 179 47 7
MultipsPrimips
n
22.1
20.7
17.4
15.715
13.8
12.611.6
10.4
9 9
7.58.2
12.4 12
10.810.1
9.28.1
7.67.1
6.45.9 5.5 5.1
4.1
1 2 3 4 5 6 7 8 9 10 11 12 13
Bishop score
0
5
10
15
20
25
Hou
rs
0
5
10
15
20
25
Average hours in labor & deliveryElectively induced patients by Bishop score, Jan 2002 - Aug 2003
10 49 130 274 567 856 1114 1266 1062 737 415 86 1918 35 61 99 164 278 375 487 453 346 179 47 7
MultipsPrimips
n
15.314
15.314.514.7
11.612.8
11.812.612.8
15.1
12.19.9
8.86.8 6.5 6 6.1
7.66.5 6.6
5.2 4.9
8.4
4.3 4.3 4.56.1 5.4
4.4 3.9
53 53
63
5357
45
5652
41
52
62
4649
35
21 2126 28
3428
2218 20
35
1518
1518
2521 20
110
87
119
109
124
91
107
94100
105
118
8781
67
57 57
4652
6055
49
3733
67
30 3036
4845
3734
Jan 20
03 Feb Mar AprMay Ju
n Jul
AugSep OctNovDec
Jan 20
04 Feb Mar AprMay Ju
n Jul
AugSep OctNovDec
Jan 20
05 Feb Mar AprMay Ju
n Jul
0
20
40
60
80
100
120
140
Num
ber o
f pat
ient
s
0
10
20
30
40
50
% o
f all
prim
ipar
ous
deliv
erie
s
Primiparous elective inductions
Bishop's score < 10Bishop's score < 8Goal: Reduce "inappropriate" nullip inductions by 50%
Elective induction: length of labor
Jan 20
01 Mar May Jul
Sep NovJa
n 2002 Mar May Ju
lSep Nov
Jan 20
03 Mar May Jul
Sep NovJa
n 2004 Mar May Ju
lSep Nov
Jan 20
05 Mar May Jul
Sep Nov
0
2
4
6
8
10
Ave
rage
hou
rs fr
om a
dmis
sion
to d
eliv
ery
0
2
4
6
8
10
8.5
7.97.5
7.16.9
(note: includes all elective inductions)
Overall c-section rate
96 97 98 99
2000 01 02 03 04 05 06
0%
10%
20%
30%
40%
Perc
ent c
-sec
tions
ove
rall
0%
10%
20%
30%
40%
National Intermountain
2001 2002 2003 20040
2,000,000
4,000,000
6,000,000
8,000,000
10,000,000
Cos
t str
uctu
re im
prov
emen
t ($)
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
10,000,000
Cum
ulat
ive
annu
al to
tal (
$)
Combined maternal and neonatal variable costDeliveries without complications resulting in normal newborns
Actual - expected cost, based on year-end 2000 with PPI inflation
Quality-based cost improvement
The healing professions are changing
From craft-based practiceindividual physicians, working alonehandcraft a customized solution for each patientbased on a core ethical commitment to the patient andvast personal knowledge gained from training and experience
To profession-based practicegroups of peers, treating similar patients in a shared settingplan coordinated care delivery processeswhich individual clinicians adapt to specific patient needs
(e.g., standing order sets)
(housestaff ::= apprentices)
early experience shows less expensiveless complexbetter patient outcomes
(facility can staff, train, supply an organize to a single core process)(which means fewer mistakes and dropped handoffs, less conflict)
Why "profession-based" practice?
1. It produces better outcomes for our patients
2. It eliminates waste, reduces costs, and increases available resources for patient care
3. It puts the caring professions back in control of care delivery
4. It is the foundation for useful shared electronic data -- an important next step in care delivery improvement
What does it taketo survive -- and perhaps even thrive --
in this emerging new world?
Part 5
Care management at the bedside
Core infrastructure:
1. Tools to change culture (clinical and administrative)
2. Tools for quality control (a.k.a. quality management)
3. Knowledge management (the key organizational advantage)
4. Administrative follow-through on clinical savings
Formal QI training programs: Facilitator Workshop Series (FWS) - 8 days in 4 sessions
Advanced Training Program (ATP) - 20 days in 4 sessions
miniATP - 9 days in 4 sessions
others (MD intro course, lab series, etc.)
that teach methods (key: hands-on projects - creates quality zealots)
change culture (key: early adopters)
improve front-line work (key: organizational learning that rolls ahead;concrete examples where others can "see the wheels turning")
pays its own way (savings from projects provide a net ROI)
Culture change that pays its way
Manage
Design
Improve
Lean designTPS: Value stream analysis6Σ: Define, measure, analyze,
design, verify (DMADV)
Technically, Quality Control (Juran)Build essential infrastructure
- key process identification- performance tracking (outcomes)- organizational structure
Accountability - e.g., monthly review
100% participation vs.breakthrough models
Identify/prioritize opportunities:- voice of the customer,- voice of the process
Rapid Cycle ImprovementTPS: A3 analysis, w/ coaching6Σ: Define, measure, analyze,
improve, control (DMAIC)
Health care as a system of production
Building infrastructure
Integrated clinical / operations management structure
1998:
(an outcomes tracking system)Integrated management information systems1997:
(mediated by payment mechanisms)cost structure vs. net incomeintegrated facility / medical expense budgets
Integrated incentives1999: (aligned)
Full roll-out and administrative integration2000:
(strategic) Key process analysis1996:
To make it easy to do it right ...(Education programs: A learning organization)(A shared vision for a future state)
Deploying EBMClinical OperationsLeadership Team
Clinical Program leadersSenior admin execs
Financesupport staff
Sr VP - hospitals, clinics, MDs
Clinical ProgramGuidance Council
regional Clinical Program MD, nurse admin leaders
Info SystemsFinancesupport staff
Clinical Program MD leaderClinical ops administrator
regional administrators
Medical directorClinical ops admin
Urban North Region Urban Central Region Urban South Region
MDs MDsMDs
MDs MDsMDs
MDs MDs MDs
CardiovascularNeuromusculoskeletalWomen & NewbornPrimary CareOncologyIntensive MedicineIntensive PedsSurgical Specialties
CoreWork Group
DevelopmentTeam
Everybody
(+ 1/4 FTE)
(1/4 FTE)(full time)
Medical directorClinical ops admin
(1/4 FTE)(full time)
Medical directorClinical ops admin
(1/4 FTE)(full time)
Development Team structureTeam leader- respected physician leader, in active practice- functionally a knowledge expert
Core work group- knowledge experts- build initial Care Process Model- provide academic detailing, run referral clinic- geographically base
Front line clinicians- physicians, nurses, clerks, techs, etc.- first level review; keep knowledge experts grounded- 2-way street: fundamental knowledge up, ownership down- geographic representation
Staff support - flow charter, statistician, data manager, clinical ops administrator
Managing clinical knowledge
1. Generate initial evidence-based best practice guideline (flowchart)2. Blend the guideline into clinical workflow
(clinical flow sheets, standing order sets, etc.)3. Design outcomes tracking reports (using electronic data warehouse)4. Design and coordinate decision support (electronic medical record)5. Design patient and professional education materials
Initial development phase
6. Keep the Care Process Model current (research pipeline; protocol variations; outcomes; improvement suggestions)
7. Academic detail front-line teams (Clinical Learning Days)8. Run the referral clinic (last step in treatment cascade)9. Manage specialist care managers
Maintenance phase
Core work group (knowledge expert) responsibility -build and maintain the Care Process Model:
No good deed goes unpunishedNeonates > 33 weeks gestational age
who develop respiratory distress syndromeTreat at birth hospital with nasal CPAP (prevents
alveolar collapse), oxygen, +/- surfactantTransport to NICU declines from 78% to 18%.Financial impact (NOI; ~110 patients per year; raw $):
Birth hospitalTransport (staff only)
Tertiary (NICU) hospitalDelivery system total
Integrated health planMedicaid
Other commerical payersPayer total
Before 84,24422,199
958,4671,064,910
900,599652,103
429,1011,981,803
After 553,479
- 27,222 209,829736,086
512,120373,735
223,2151,109,070
Net 469,235
- 49,421 -748,638-328,824
388,479278,368
205,886872,733
115
74
75
81
88
88
92
97
97
106
107
109
109
129
130
132
UtahFranceJapan
SwedenAustralia
CanadaNorway
NetherlandsGermany
AustriaNew Zealand
DenmarkU.S.
IrelandU.K.
Portugal
0 20 40 60 80 100 120 140
0 20 40 60 80 100 120 140
Deaths per 100,000 population
Mortality amenable to health care
Source: World Health Organization, Nolte and McKee, Rutgers Center for State Health Policy Standardized for age (1998)Utah from 2003, normalized for general US change from 1998
Wells Fargo inflation summary, 1988-2006
The Wall Street JournalPerverse Incentives in Health Care
April 5, 2007John C. Goodman, President, National Center for Policy Analysis
Research at Dartmouth Medical School suggests that if everyone in America went to the Mayo Clinic, our annual health-care bill would be 25% lower (more than $500 billion!), and the average quality of care would improve. If everyone got care at Intermountain Healthcare in Salt Lake City, our healthcare costs would be lowered by one-third.
Of course, not everyone can get treatment at Mayo or Intermountain. But why are these examples of efficient, high-quality care not being replicated all across the country? The answer is that high-quality, low-cost care is not financially rewarding. Indeed, the opposite is true. Hospitals and doctors can make more money providing inefficient, mediocre care.
"I am sorry for you, young men (and women) of this generation. You will do great things. You will have great victories, and standing on our shoulders, you will see far, but you can never have our sensations. To have lived through a revolution, to have seen a new birth of science, a new dispensation of health, reorganized medical schools, remodeled hospitals, a new outlook for humanity, is not given to every generation."
At the opening of the Phipps Clinic in England, near the end of his career. Cited in
-- Sir William Osler
Reid, Edith Gittings. The Great Physician: A Life of Sir William Osler. New York, NY: Oxford University Press, 1931 (p. 241).