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Juxtaposition — our son's finger and our car's battery

January 19, 2010
by Joe Bormel
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Juxtaposition – our son’s finger and our car’s battery

Yesterday. Two real events, one healthcare delivery-related, the other, the diagnosis and treatment of a car battery problem. Those two events coincided with my completing reading a worthwhile, 17-page article by David Goldhill, “How American Health Care Killed My Father. The relevance of Goldhill’s article was striking. First the healthcare event.

Emergency Department and Post-acute Surgical Care

Our eight-year old son was unfortunate enough to have had his finger crushed in a door at school. It was an accident, unrelated to the intentional or avoidable behaviors of anyone. It was very scary, and will likely become only a sad memory. Thanks to careful, cautious and competent work by the emergency department at a community hospital, and follow-up with a hand surgeon, our son is likely to have a functionally and cosmetically normal finger within a few months. What about the quality and costs issues?

The costs, coordination and follow-up care issues were typical of U.S. healthcare. We were told in the ED that the follow-up surgeon, scheduled for the next day, would be covered by health insurance. When we arrived at his office the next morning, we were told that wasn’t true. The office was in no way connected to either our pediatrician’s office or the emergency department (relationships or shared records text, or radiographic images), or any sort of system that would help organize and convey the management, costs and follow-up issues.

The surgeon was in another state, and according to Google directions, an hour away accounting for known traffic. This is in a major metropolitan area with a high density of doctors, academic medical centers, and the NIH (across the street from the hospital). That said, surgeon-in-another-state’s skill and the surgical outcome of the re-implantation to date are superb. We are truly grateful, although we had no real discretion to make a choice, assess price or other options.

We had no real choices in this situation, other than to follow a guild-based referral that was costly, inconvenient, and fragmented. See my post on selecting an orthopedic physician for our daughter in the post Relativity and Reality . In that instance, it took sophisticated consumer parents and four medical opinions to arrive at a clearly superior option – an option that factors in over a decade of Comparative Effectiveness Research that’s already completed but not locally valued. With our daughter, we had the luxury of time and a huge measure of parental energy. Conversely, the quality of the opinions for our son was objectively limited and the costs incurred were significant.

DieHard Battery Care

Contrast all of that with my DieHard battery experience. I’m thinking about apologizing for the not-so-subtle slight to the U.S. healthcare system by even making this comparison. But I’m not ready to apologize. I'm also eager to acknowledge that surgical skill cannot be compared adequately to commodity automotive service ... at least not superficially.

I needed to jump start my eight-year old car (jumper cables to another car’s battery) a few weeks back after a cold snap, combined with a child leaving an interior light on in the vehicle's backseat. The car seemed back to normal after the jump, but then seemed a little questionable over the ensuing weeks. So last night after work, I pulled into the local Sears automotive center, conveniently three miles from home.

We were quickly triaged. Two minutes later, my car was inside their large garage, the battery was attached to a test rig, and the same agent was completing my registration process. This included reviewing my car’s service record while the battery was being tested, automatically, against simulated loads. No more than ten total minutes from my arrival and I was told, “Your battery needs to be replaced, and the prorated price, with service will be $48.” I signed the printed history and physical document that included an assessment, detailed plan and estimates for length of stay and final, negotiated price.

My daughter and I went to dinner, came back, and found, in addition to the set expectations, there was a print-out of a comprehensive check-list for this problem, and results of performing the checklist attached to the bill. In other language, there was a clinical discharge summary that was complete to a best-practice standard of battery care. The alternator and other electrical things had been tested and documented to be okay.

My take-home lessons:

• My juxtaposed experiences served to support Goldhill’s conclusions. Pouring more reform money into a healthcare system that uses the government and others to pay for care will not improve quality, access or the cost dynamics of care delivery. Neither emergent care or episodic.

In a consumer-centric system, the surgeon would have seen my son in the local emergency department, on the initial visit, within two to three hours. It would have been at pricing that was either covered by insurance (and their negotiating practices), or value-priced and concordant with some managable payment scheme (HSA, credit, etc), with clear expectations, and concordant with felt-fare pricing practices. The felt-fare pricing would be driven by paying appropriate rent for expertise and 24x7 availability of the practitioners, not by an opaque and distorted approach to economics. See Goldhill's treatment of accounting, moral hazards, and impacts of cost shifting in his article.

• The whole patient-identifier challenge . . . could it have actually been more of a hoax then I was led to believe? As Goldhill and others point out, health care organizations seem to be able to identify us reliably enough to bill our insurers. Back in the consumer world, Sears had a phenomenal history on my car; an integrated record (financial and clinical) with sub-second screen flips, with a TDS-4000/7000 style interface. From the looks of it, I'm guessing Sears hasn't spent a million dollars modernizing the user interface or redesigning it architecture in well over a decade.

Organizing our healthcare system around payers and not consumers, (including consumers legitimate concerns around privacy and confidentiality) impacts consumers very negatively. And, I don’t think Sears needed tax-payer dollars to fund its IT infrastructure requirements. Sears also didn’t need the initiative thrust upon it by the government.

• To re-state my concern from my recent experience with our son’s emergent care, and Goldhill’s experience of his fathers death:

“The government’s reform plan will ... feature a variety of centrally administered initiatives designed to reduce costs and improve quality … a major government investment to
• to promote digitization of patient health records,
• an effort to collect information on best clinical practices, and
• changes in the way providers are paid, to better
• reward quality and
• deter wasteful spending.
they simply do not address the root causes of poor quality and runaway costs.” [Goldhill]

I won’t attempt to summarize Goldhill’s arguments and recommendations. Read his paper, it's worth the effort. My family’s experience with our son’s episode-of-illness is a non-exemplar, that is, not the way you or I want to get care. The healthcare system, including it's quality and costs, would likely better mirror my cost and quality experience dealing with my DieHard battery. In one visit and about an hour of clock time, I conveniently had my problem diagnosed; checklists and order sets were used; documentation was automated. Care was delivered as one encounter, care coordinated appropriately, including bringing providers to the problem. The medical, surgical and family's costs were clearly established, accurately and as early in the process as possible. Not accidently, the bill went to the recipient of the service.

If we started addressing these root causes, i.e. our payment system and the over arching impact of the distortions it causes, health, healthcare and healthcare delivery would be improved. Centrally pouring more money into the current system cannot fundamentally improve the quality or costs we experience. Goldhill is right. Based on my experience shared here (and his shared in the article), it's hard to be confident that the reform being discussed will address the root causes.
 

My take on Goldhill's proposalIn addition to reading Goldhill's paper, I was able to read several dozen reader comments. There's general consensus that Goldhill's characterization of the health reform issues is accurate. His suggestions for reform aren't radical from the standpoint of a lot of important work by economists, academics and government policy makers. The government, for example, has been driving transparency.

The messy part, in my opinion, is that all of the stakeholders have made investments based on expectations of the current financing model. The notion of phasing in a new, reformed model over a generation is too vague for any payer, provider, hospital, pharmaceutical or device maker to get excited about.

I think this is a show-stopper, unless it's addressed. Many hospital CFOs, for example, do not have the means to cover pension commitments. Many providers have training and practice debt. Even reform that's designed to roll in over a generation or two needs to address these realities. The capitalistic realities of other healthcare firms are an equally formidable issue that's barely (if at all) addressed when comparing the U.S. to other countries.

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