prevention versus productivity

July 12, 2009 — 9 Comments

Apologies for being off-line but I have been taking a bit of r&r.

The current debate around health care reform is both interesting and depressing. While it is reassuring to see America finally tackle the issue of universal health care access the bigger debate about affordability seems to be going nowhere. Much of the conversation seems to be based around the role of prevention in bringing health care costs down but as Matt Miller pointed out in his Fortune article, prevention does not bring down the cost of health care – if anything it may actually force it up. He argues that a high proportion of health care costs happen in the last few months of life and no amount of prevention can avoid the inevitable.

This may be an extreme argument and few would argue that reducing obesity or smoking and increasing excercise does not have a beneficial effect. However it is correct to assert that prevention alone will not create a sustainable and affordable health care system. And system is the operative word here. Innovations have to occur across the whole system if sustainable change is to happen.

Productivity is just as important as prevention when it comes to creating affordable health. The tendency is for the political argument to jump straight to rationing as the cost control strategy but I believe there is a wealth of opportunity for innovation that creates greater productivity. Some of that will come from technology (although there are precious few examples of that so far) but much can also come from process innovation. Kaiser Permanente found ways to bring the time it takes nurses to change shift down from 40 minutes to 12 by going through a design based exploration led by nurses and other practitioners. Multiplied by every nurse on every shift on every ward in all forty hospitals this added up to a huge amount of extra time available to serve patients. The key here was that the innovations came from the ward floor, not from the executive suite, never mind Washington. Getting design thinking into the hands of health care practitioners may just offer one route to affordable health.

Tim Brown

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9 responses to prevention versus productivity

  1. Tim, totally agree on the potential for productivity through process innovation. In fact, there is a growing practice in applying the Lean Management principles pioneered by Toyota to improve healthcare processes using lots of “common sense” techniques. But innovation in redesigning the processes isn’t enough – we need to look at the underlying metrics because ultimately people behave the way they are measured – and in this case, we are talking about changing the behavior of the healthcare providers (nurses, doctors, administrators, etc.)

    I love this quote I came across: “Most people don’t change because they see the light, but when they feel the heat.”

    Right now, its the patients (customers) who are feeling most of the heat and I believe as a society, in the long term, we will change by adopting more preventive habits to improving our health. What confuses me is how the “heat” is applied to the provider system that induces change that creates value for the patient…frankly, the health care reform dialog seems so convoluted that its more likely we’ll end up treating symptoms and not the root causes. The solutions are out there – I just don’t believe the physicians are ready to hear “heal thyself”.

  2. This is such a complex issue and I do agree that innovation by the working force (not the management) and practices like Lean will be beneficial as part of the solution.

    There are a couple of other problems that I am not sure what the solutions are.

    It appears that the patients demand a high expectation from the providers – that they will have an answer to every problem – and if they stop looking (ordering tests & driving up costs), the customers/patients would be dissatisfied. In some cases, if alternative care/health (accupuncture, massage, homeopathy, herbal remedies, mind/body work) was more embraced by providers/insurance companies, cheaper solutions could be tried first and potentially solutions found prior to the high cost ones.

    Second, the ethical practices of doctors/medical providers owning both practices and testing facilities does seem questionable. How can the patient’s interests be best served when the provider’s income/profits trump the patients care? It seems globally (not just in health care – also financial services due to recent meltdown), ethical practices need emphasis & clean-up and some oversight in order for these relationships not to drive up costs for everyone in order to line the pockets of a few.

    There is danger in just focusing on one aspect of this overhaul. All aspects need to be considered in order for a sustainable solution to be implemented.

  3. Well stated, Tim. I agree that getting design thinking into the hands of healthcare practitioners is great avenue to pursue as we seek to manage costs. Beyond productivity, the immersive nature of design thinking also offers the potential improve the quality of outcomes for patients and the quality of the experience for healthcare professionals.

    As an aside, I suspect that many gains from process innovation will center around communication. Nurses and other practitioners have key insights for improving processes and information flow, but are not likely to have the expertise needed to optimize communications artifacts like forms, instructions, or checklists (whether paper or electronic). Raising awareness of the benefits of effective communications design may amplify the potential gains of a design thinking approach.

  4. Very much agree with the importance of innovation coming from the ward floor (patients are also source of innovative organization of healthcare) but once change shift has been brought to 12 minutes vs 40, what will be next : more patients ? in this case even if change shift takes 12min., extra time could not mean extra availability for patients…

    more effective communication design should also be considered from the patient’s view. I have the impression patients are not enough taken into account for innovative design in healthcare policies/systems and rather absent from debates Tim speaks about

  5. Interesting article with healthcare issues appearing no different in the US. As a ‘worker bee’ within the National Health Service in the UK we are making progress in system re-design to improve the patient’s timely access to services and treatment within tight budgetary confines. The aim of any healthcare system must be to keep people well and out of hospital and finding a balance between prevention and productivity will always need innovative solutions. The problem is that most of us want to eat our cake, wash it down with beer or wine now we have given up smoking!

  6. Tim…

    Your attempts to put organizational decision making into the hands of labour and patients are commendable.

    One of the things that he US system suffers from is in fact its focus on innovation and not careful delivery the of health care solutions. The balance is off to the benefit of those that drive profits. Too much emphasis on changing the system and not perfecting the ideas and procedures that have been implemented. The staff and physicians are never able to perfect their delivery methods as they are always preoccupied with changes that are coming down from management and their consultants.

    Additionally, the rewards go to the creators of innovation while the implementors of their innovations continually receive more hours and less compensation to perform their duties. A classic labour management struggle. This is what causes a reversal of improvement in care and leads to patient neglect and organizational inefficiency.

    Last month I received a full (free) physical examination from a private hospital in South Korea, and must say that the efficiency and productivity displayed by the staff and physicians was bar none. All corporate organizational decisions in Korea are top down by the way. This experience illustrated how the US system is focused on change for change and profit sake, and South Korea, like its manufacturing sector, appears to be a system focused on perfection of method and delivery, and not profits.

  7. The “innovation coming from the ward” is the most important phrase. This will not only insure that the innovation and/or design is effective, but that it is also sustainable. We call this “bottom-up design” as opposed to “top-design” design. We apply it to software, but encourage it in the design of any product/service/process. Etc…

  8. The idea of ‘shop floor’ sourced innovation is nothing new. As an R&D intern 10 years ago we utilized the Kaizen event method as taught by the Toyota Production System structure to pull insights from everyone involved at all levels of the process. Quite often the people with the best ideas are the one who live at the most rudimentary levels of the process. They perform repeated tasks and come up with great ideas. It’s truly a shame when these insights are overlooked by those who operate at the higher levels of the process when trying to optimize.

    http://en.wikipedia.org/wiki/Kaizen

    I’m now working on improvements in the transfusion safety process to help hospitals and bloodbanks reduce dangerous and costly errors. This is an increasingly urgent priority for facilities after a new Medicare rule which states that hospitals will no longer be reimbursed for treatment given as a result of one of several complications that are deemed “preventable” by the hospital. This provides some much needed motivation for facilities to look critically at their processes to ensure the highest level of care…or else they will foot the bill. To ensure the vigilance required to prevent these errors efficiencies will need to be discovered elsewhere. The result should be two-fold: increased quality of care with overall lower costs of care.

    http://www.nytimes.com/2008/10/01/us/01mistakes.html?_r=1&ref=todayspaper

  9. Thomas Wicker July 18, 2009 at 9:30 am

    Interesting – when I first saw the title of the post, I thought you were going to go in a very different direction.

    First, about Miller’s article: note that “behavior change” is also preventive medicine. However, right now, our providers are reimbursed (“held to the fire,” as Sree might put it) for treating diseases like diabetes, not for getting people into, or keeping people in, behavioral-change programs such as nutrition management programs, fitness/weight-loss programs, etc. Even Miller notes that these preventive strategies would help the situation. However, in a world where insurance companies expect you to change your provider every 2.5 to 3 years (source: J&J), there’s no incentive for them to provide dit squat towards improving your health in 10 years.

    Second, the “prevention isn’t cost-effective” debate (incl. Miller’s article) overlooks a major, major factor: if someone dies from preventable causes at, say, age 50, then society has lost several years of productivity from them (and the people who *aren’t* going to doctors are the ones who are typically the most able to benefit from preventive lifestyle changes). We’re losing well over a decade’s worth of productivity from that individual – and we’re cheapening our society’s view of the value of life, such that people will be more hedonistic and less likely to be concerned about the future and their childrens’ futures (I won’t get into those effects here).

    So – you’re right that looking at prevention through pharmaceuticals/doctor visits isn’t going to be the main driver for lowering healthcare costs, and might end up raising them, and you’re right that looking at other ways of lowering costs are desperately needed. That said, my points are that we’re not looking at the broader picture and what end users (i.e., those of us who are US citizens) really experience, up to and including the work we do, the families we raise, the communities we’re in, and the future we create.

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