Ian Morrison

Everywhere I go in health care as a patient, a family member of a patient or a futurist, I see that people in health care are really busy. Actually, frenetic is a better term. Doctors are frantically pedaling to keep up with medical innovation; declining reimbursement; and waiting rooms full of patients who get older, fatter, crankier and more demanding every day. This is the hamster care I have described elsewhere: Doctors are like hamsters on a treadmill of discounted fee-for-service, scurrying faster and faster to make their target income as real reimbursement per unit of service declines.

But nurses and other caregivers are even more harried. They live in a world of hyper-documentation, of HIPAA compliance, of measurement of everything, of endless meetings and exhortations for performance improvement, all enabled by information systems that are feeble, disconnected or nonexistent.

Health care delivery is like Jet Blue on a bad day, trying hard to be cheery when it is overwhelmed.

High-Tech Chaos

As my wife was being cared for recently in a prestigious teaching hospital with magnet status, fabulous doctors and nurses and shiny new buildings, I watched the nurses scribbling on Post-it Notes that they placed on top of the keyboards of expensive mobile workstations that seemed to be permanently disabled. There were signs about infection control processes, warnings about name duplication of patients and exhortations to wash hands everywhere you looked–a disorienting blizzard of quality improvement information.

My wife was surrounded by, and plugged into, an assortment of expensive-looking machines that we Americans love so much. “Machines that go ping” Monty Python once called them. No one seemed to pay much attention to them or the alarms that went off. The very expensive bed moved itself periodically, whether you wanted it to or not, making it virtually impossible for the patient to get comfortable.

Every few hours a whole new cast of characters became my wife’s caregivers. Everyone did a great job, but I was struck that no one in their right mind would actually design work processes that way. Health care delivery really is Pimp My Ride writ large, with layers of gadgets and technological excess on a tired, old, and beaten-up chassis.

More recently, as a nation we experienced shock and awe that our brave military folk who have been wounded in Iraq are not receiving seamlessly coordinated care, that health care information systems for veterans don’t talk to one another and that there are significant failures in integrating sophisticated acute care with the rehabilitation and management of chronic conditions and serious mental illness so epidemic in Iraq veterans. But that’s no different from the rest of us.

A Stop to the Madness

I do not blame the valiant doctors and nurses who are trying their best. I think they are overwhelmed. So I am proposing a mammoth time out for health care. Here is how it would work:

Declare a technology moratorium. No new drugs or devices would be approved for two years until we learn how to properly use the ones we have. I would suggest we pay the manufacturers exactly what we are paying them right now, but instead of selling new stuff, they send all their smart people into the hospitals and doctors offices to apply their sophisticated business acumen in redesigning care processes so that they are efficient and effective. The technology vendors could still do R&D on new products, but the rules would be different when the moratorium ends: We won’t buy anything unless it is better, faster and cheaper than existing methods, otherwise it’s not happening.

Ban the consultants. Futurists and health care consultants would be banished for two years unless they were prepared to do bedside management engineering, helping doctors and nurses design care processes that really work. There would be no conferences about the future of health care, PowerPoint presentations would be outlawed and there would be no national meetings, unless they were authorized by Don Berwick.

Freeze the insurers. All insurers would be required to keep all the members they currently have. There would be no marketing or dropping of coverage, and all the money saved from their marketing budget would be sent to the Time Out Czar, who would use the money to build a new delivery system from scratch for the uninsured.

Shut up the politicians. Politicians would not be allowed to talk about health care unless they specified how it was going to be made more affordable. Promising Magic Kingdom entry passes to a dysfunctional health care delivery system would be banned.

Furlough the doctors. All doctors would be furloughed at a salary of $500,000 a year for a specialist and $200,000 a year for a primary care doctor. They would be called back to staff a redesigned delivery system as needed. This suggestion actually might save a lot of money, because physicians’ net income is only about 10 percent of health care costs. It is the economic havoc they wreak trying to get that income in a fee-for-service system that causes all the problems.

Zero-base the delivery system. Starting with the uninsured, the Time Out Czar would design a rational delivery system. I started my health care career doing zero-based budgeting in Canadian health care. It was made fashionable in the late 1970s by Jimmy Carter, but the premise was simple: What would you do with your first dollar of expenditure, then with the next layer of spending, and so on, all to reach the optimum outcome?

At a recent meeting of emerging global health care leaders from Africa, Asia, North America and Europe, I suggested that if you took the zero-based approach to health globally, you would start with spending your first health care dollar on clean water and condoms, then add lady health workers (as they do in Pakistan, where local women, not nurses, are empowered to give basic prenatal care, dramatically reducing infant mortality), then add immunization and hydration therapy for infants, then capitated primary care (as they do in Chile), then free generic drugs (as in South Africa), then basic outpatient surgical services. All of this could be done for probably less than $1,000 per capita, even in the United States. You would have to spend much more before you ever built hospitals or bought MRIs, but even developing countries fall into the trap of building fancy Western hospitals as a symbol of a great health care system.

Obviously, this is not a serious proposal. But if we do not pause and reflect; if we do not start to set priorities based on cost-effectiveness criteria; if we do not change the reimbursement system for providers to reward outcomes, not volume of marginally effective services; if we do not become more judicious in our introduction of new technology, we will bankrupt ourselves. We will create millions more uninsured and underinsured, and we will have no policy options left.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN OnLine. This article 1st appeared on May 1, 2007 in HHN Magazine online site.