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June 13, 2009
by Joe Bormel
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The 1968 John Wayne movie, Hellfighters, has just stuck with me. IMDB reduces the plot to this: "

The story of macho oil well firefighters and their wives. "

When the Hellfighters are fighting the first oil well fire, they explode nitroglycerine over the oil rig to extinguish the fire. While burning, in addition to the intense heat, these fires often fill the air with acid and poisonous gas.

The movie culminates with a fire where several oil wellheads in relatively close proximity are all burning simultaneously, and extinguishing them requires simultaneously and precisely detonating the nitroglycerine over each of the heads. Being Hollywood and all, there are also guerrilla terrorists taking riffle shots at our heroes while they're trying to achieve an otherwise nearly impossible, heroic task. And of course, the key characters are on the brink of failing marriages, so they're bringing their wives with them into these dangerous places. Phenomenal action and drama ... just like healthcare improvement initiatives in the U.S.?

Excuse me? Where did that come from?

Here's my point. Improving the healthcare delivery system will require simultaneous solutions; otherwise, a tweak here or there will simply inflame the problem somewhere else, probably explosively. Here are two clean but simplistic recent examples:

Fixing Health Care Starts With the Doctors

By Steven Pearlstein, Wednesday, June 10, 2009

It's the

doctors, stupid.

If we really want to fix America's overpriced and under-performing health-care system, what really matters is

changing the ways doctors practice medicine, individually and collectively. ...

... and

the first reply comment (when I read it; it's no longer the first reply) ...

camiolo wrote:

"Like many health reformers,

Gawande says the essential problem with the American health-care system is that so much of what we spend -- as much as a third of the $2.3 trillion spent in 2007 -- goes toward care that is either unnecessary or inappropriate. Fixing that is the first step to fixing everything else."

Wrong. The first problem to fix is

paperwork. There's so many different forms that need filling out depending on which insurance plan the customer is on. And once everyone is on the same paperwork path, we can start to accurately track and measure the consumption of Health Care. Then we can decide what care is unnecessary or inappropriate.

I and other bloggers here, most recently

Pam Arlotto in her Whack-A-Mole post, have pointed out that the healthcare performance challenge is a system issue. A focus on the underlying processes is essential.

In the spirit of Hellfighters, I think that the most parsimonious characterization of the problem we're trying to address, in part with HCIT, has three elements:

Cost, Quality and Access. In political speak, increasing the number of covered lives, while simultaneously and dramatically reducing the national costs for healthcare. Each of them requires behavior change and payment reform that are simply flip sides of the same economic coin. Simplistic deductions like "the doctors are the problem" or "paper is the problem" or "payment/payors" or "consumerism out of control" or "attorneys" or "obesity" or "greed" are the problem reduce a complex situation to an absurd caricature. Elevating the importance of one fire over another, or discounting the significance of a non-pet component of the issue will not lead to improvement. Quite the opposite.

I've outlined

my thoughts on where to start in Vowels of Care, which is a systematic thought.

If you're interested in reading an intelligent elaboration of the components of healthcare reform and the sloppy thinking, you'll find that in the comments starting with camiolo's above (

link). (The roofing analogy really struck me as right on. So did radiotesla's wife.)

Healthcare reform is a Hellfighters scenario.



Red Adair was the inspiration for oil well Hellfighters.

There are a lot of modern day heros. A challenge is that we/they all have a relatively limited sociopolitical scope, resulting in a very high casualty rate.

That said, there are Red Adairs in our world. I'll start the list, but challenge you to add to it!

Don Berwick and the work of the IHI are objectively Hellfighters. We wouldn't have the Lives Campaigns which were broadly adopted without their work. Much of my personal inspiration has come from Don and the IHI initiatives. For example, re-framing Patient Safety as truly being about High Reliability Organization thinking came through the IHI.

Ten years ago, Don wrote a plenary presentation called Escape Fire. It laid out the broad healthcare delivery problem and laid the foundations for various collaboratives and the STEEEP framework.

So, Pam, who are the Hellfighters of healthcare?

Why do we wait until its a fire? Why do we wait until its broken to fix it? When the family comes to me with the 110 pound 7 year old child, I ask where were you at 80 pounds?

The healthcare problem is far more complex than all the above profound comments multiplied by a thousand. Where were the reforms in the 70's and 80's as hospital costs skyrocketed? Why didn't the savvy business people notice as the administrative/management costs of medicine grew in proportion to the actual costs of clinicians and treatments?

Payor issues.
Malpractice issues.
Best practice issues.
Death with dignity (90% of the dollars spent on 10% of the patients?)
Overspecialization. (Every headache doesn't need an MRI)
Healthier base population. Capitalism and the luxury life has created a nation of diabetics.
Generic drugs work! Let's use them. $200/month branded prescriptions? Come on!
Digitally assisted practices are more efficient. Why not start with a lower cost, open source solution rather than pouring gazillions of dollars right off the bat on proprietary systems?
And the list goes on...

Doctor B, you've struck on a very basic, deep truth. In perhaps too many cases, people do not act until there is a large enough crisis. It's well recognized in Washington DC that it takes a large enough event to change the status quo, no matter how logical, obvious, or otherwise clear the problem and solutions may be.

In a recent episode of manager-tools, Michael Auzenne and Mark Horstman say: "Emotions, Not Facts, Are What Cause Change ... Sorry." See: http://www.manager-tools.com/2009/06/change-leadership-whats-my-visual-p... for complete podcast.

As you've validated with your comment, it's empirically true that humans often need fires before acting, especially when a problem is complex.

I agree with your observation that the list itself is very important. The only lament I'm adding to the dialogue is that piecemeal fixes to core problems (administrative costs, attention to effectiveness, incentive alignment, outcomes, and the uninsured) cannot work. And, in our domain, better, faster, and/or cheaper health care information technology, by itself, is as likely to worsen care and costs, as it is to improve them.

As with Hellfighters, anything less than a simultaneous solution to the hottest spots cannot work.

Thanks for chiming in on this conversation.

Jack, Thanks for the kind comment. The central fires are around what we value and the resulting needs for payment reform. Non-visit-based care and the movement toward team-based care (Medical Home) are important trends to watch which I and many others have addressed previously. As I've already expressed, my reduction is closest to that of camiolo's above - the administrative burdens on scheduling, coordinating, delivering and paying for care are relatively low-hanging fruit. This also came up in the recent (June 10, 2009) Knowledge@Wharton article titled Information Technology: Not a Cure for the High Cost of Health Care.

Interesting analogy, but in Red's world he had a big advantage. The client benefited directly and the client paid his bill ( or didn't if the fire wasn't out). In our world a third party pays the bill, and the client (patient) has to decide if the fire is out or not. It's a very different market dynamic.

So Joe, who are the Hellfighters of healthcare, our own modern day heros?

Thanks for your comment Frank. That's a very good point.

Your point, that the healthcare system isn't a system and the healthcare market isnt a market, is absolutely part of the challenge / predicament.

In the healthcare "oil well" concurrent fires metaphor, there's clearly
1) payment reform to drive provider and consumer behaviors, and
2) HCIT to enable better, more reliable processes (like follow-up of results, consults and impact/effect of treatments.)

It is a different market and consensus is more complicated.

IA, thanks for your comment. Your comment echos that of Dr Coye.

At the X3Summit this week, keynote speaker, Molly Joel Coye, MD, MPH, CEO, Health Technology Center, gave the keynote "Technology, Health Design, and Innovation of Care — Why this Conversation?"

Part of the talk centered on "Disruptive technologies" which do, very much, blow up existing paradigms of care.

A complete article with interesting examples from HEALTHAFFAIRS,  Volume 25, Number 1, page 163 by Molly Joel Coye and Jason Kell is freely available here:


Here's a telling excerpt:

 “Disruptive” technologies. When technologies are disruptive, operating and
financial impacts are challenging to estimate, which makes it difficult to construct a
“business case” for investment. Hemofiltration, for example, has been developed to
shorten the time required to remove excess f luid from the circulation of certain pa-
tients with congestive heart failure (CHF). (reference 15) It is used in intensive care units (ICUs),
but its use will expand to the emergency department (ED) in the near future and
eventually to outpatient facilities. Over time, this shift in care setting will greatly re-
duce the use of ICUs and EDs. But the resulting impacts on ICU and ED usage, elec-
tive surgery, and nurse staffing are difficult to estimate. CMS decisions about cod-
ing, coverage, and reimbursement rates are also difficult to anticipate in the case of
disruptive technologies yet will greatly inf luence adoption rates. Hospitals could
reasonably fear losses in this uncertain environment, despite potentially beneficial
results for patients.

Disruptive technologies make it difficult to conduct return-on-investment
(ROI) analyses. The recognition that even nonprofit hospitals needed to improve
their business management in the 1990s led tr ustees and executives to demand
ROI reports to justify many capital investments in new technologies. In cases such
as investment in a new computed tomography (CT) scanner, ROI analyses are a fa-
miliar exercise for hospital planners, based on acquisition cost, expected volume,
and known reimbursement rates. The same cannot be said for disruptive technol-
ogies such as surgical robots, picture archiving and communication systems
(PACS), or computerized physician order entry (CPOE) systems. Each of these
emerging technologies adds more uncertainty regarding operating impact, reim-
bursement, and ROI—and further complicates the capital planning process. (reference 16)

Thought provoking post. Although a list of healthcare Hellfighters would be of value to review and debate, I think a list of the fires they need to fight right now would be more interesting. I'll leave it to you and the other learned bloggers on this site to inform us of your thoughts on priority.


Interesting post, Joe. One big difference between Red Adair's Hellfighters and today's healthcare situation- Adair was called in by the responsible party (not a responsible party) and was then given carte blanche to blow things up. In healthcare, there doesnt exist a responsible party, there are many. And, you are right, there's a growing realization that some things need to be blown up to improve healthcare delivery.