Vol. 67 May 15, 2012 Our Health Care System: A Symphony Orchestra or A Herd of Cats?

 AMA chief executive James Todd, MD, jokes that leading physicians is like herding cats. Princeton health economist Uwe Reinhardt, PhD, compares it to making eagles fly in formation.  – AMA News, 1993

Two well-known analogies of our health care system came to mind the other night while I attended a concert of our local symphony orchestra.

The “symphony orchestra analogy” originated, or so the story goes, from the tension between a hospital administrator struggling with rising costs and decreasing reimbursement and the hospital’s Board. The Board Chair continually challenged the administrator to increase efficiency and reduce costs. The Board Chair also happened to be on the Board of the local symphony orchestra. One night the hospital administrator attended a concert, and wrote this letter to his Board Chair the next day:

“I enjoyed the concert last night very much, and you are to be congratulated on your effective stewardship of this important asset to our community. However, I couldn’t help but notice that the French horn players only played about 17% of the time. Surely they could be playing other instruments at other times with a little cross training. The two soloists, one alto and one soprano, seemed very underutilized. They only sang during the third movement. It seemed a wasteful use of your most expensive professionals by having them just sitting there gazing at the audience for most of the time. The forty violinists were impressive, but surely you could have gotten along with 35 or even 30. The drummer seemed to be the most efficient and was obviously cross-trained. He played almost all of the time by having a triangle, castanets, and car horn to fall back on when not beating a drum. Finally, couldn’t a less expensive automated device replace the pianist’s page-turner?

I am sure that you could probably cut 10-15% of the orchestra’s budget if you just implemented these logical changes.”

Just re-reading this and substituting “gastroenterologists” for “French horn players”, “cardiac surgeons” for “soloists”, and “primary care physicians” for “violinists” belabors the point.

The parallels between the musicians in the orchestra and physicians are more numerous than you might think.

Both are highly trained over many years. Both are said to practice.
Both are highly specialized. (one instrument or one organ system)
Both have to prove their competence. (auditions or licensing and credentialing)
Both are independent professionals that may periodically play together. (a concert or cardiac surgery)
Both get specific instructions for performance ( a musical score or practice guidelines)

What then is the big difference between musicians and physicians? Besides their pay scale (thay difference may be smaller now for primary care physicians), the big one, right off the bat, is that the musicians in an orchestra have a CONDUCTOR to help them play together.

Who can help the health care professionals to play well together? The Federal government? Clearly Congress has said “No”, even to a highly qualified physician “conductor” like Donald Berwick, MD. And, of course, the orchestra conductor is leading music that was written by someone else. (Congress?)

Are we left with just “herding cats?”  The Affordable Care Act calls for the creation of Accountable Care Organizations (ACOs) to improve quality and reduce costs. An ACO may include physicians (cats), hospitals (dogs) and patients (rabbits). Can they work together to work with, and even protect themselves from, the wolves (health insurance companies)? The first 27 ACOs designated by the federal government have been mostly physician-run, only a third of them even involve hospitals, and they cover a very small number of patients. The next round of 90 ACOs to be designated on July 1 will give us a better idea about this attempt to “herd cats” regionally and a better view of any potential impact on our health care system.

In the meantime, the music plays on.

Oops, there I go mixing metaphors.

But that may be “the answer”. Our health care system is just that, a really mixed up metaphor.

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