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.
Vol. 43 April 15, 2011 “I Told You So”
April 15, 2011“The [U.K.] proposals draw heavily on market-style incentives to drive improvements in outcomes and increase responsiveness to patients and the public. But they also include new arrangements for accountability, fundamental changes to the structure of the NHS, and a shift in the responsibility for paying for health services to groups of capitated physicians. (1)
Sound familiar? Those words describing the current British health care reform effort could serve as a description of U.S. health care reform and the creation of Accountable Care Organizations (ACO). I know I bill myself as an “evidence-based” blogger, and therefore distant from the personal ranting, either angry or self-serving, by other bloggers, but this article in the New England Journal of Medicine spurs me to electronically shout out in triumph, “I told you so!” In my blog (2) and in a paper (3) I wrote in 1967 (when?) I opined that there seemed to be more similarities than differences between the U.K. and U.S. health care systems. This well-researched article in the NEJM agrees with me.
BOTH the U.K. and U.S. reform acts:
Seek to reduce costs by making providers accountable for total per capita health care costs ($32B less for U.K.over 5 yrs. and $100B less for U.S over 5 yrs.)
Seek to strengthen primary care
Remove payment incentives to increase volume of patient visits (Pay for “value” in U.S.; “fixed budget” in U.K.)
Do NOT require providers to “bear risks” for catastrophic illness like insurance companies do now (but that is an option for ACOs in U.S.)
Primary Care Physicians (PCP)
While the U.S. pays lip service to strengthening the PCP, the U.K. proposal really means it. U.K. will give the general practitioners CONTROL of over 70% of the NHS budget! The GPs will form primary care groups called GP Consortia. These Consortia will buy additional care for their registered patients from hospitals and specialists competing for contracts. 170 Consortia have already been formed and another 100 are being planned. A physician-run ACO in the U.S. would be similar, but the ACO would include both primary care and specialty physicians like present day multi-specialty groups. No one knows how many ACOs will be developed, and many of them will be formed by hospital systems.
Commentators on both sides of the Atlantic have voiced concerns that physicians will not be able to deal with these new managerial responsibilities successfully; physicians in neither country like to develop budgets, live by budgets, or even value management/administrative skills.
Quality Incentives
In the U.K. the National Institute for Health and Clinical Excellence (NICE) will set care quality standards for the Consortia and the contracts they grant or “commission”. The Center for Effective Research (CER) established by the U.S. Affordable Care Act will have the same role of issuing standards of care. The practice of setting national targets for care will be dropped in the U.K. to be replaced with “a system of open reporting of data on performance and clinical outcomes.” This newly available data will allow patients (“the market forces”) to choose high quality care among the “any willing providers” in the absence of national targets and differential prices. As in the U.S. there is little evidence that patients actually use such data when it is available to make decisions about where to seek care.
Two Big Differences
The U.S. ACO incentivizes coordination of care between primary care, hospitals, and specialist physicians. The U.K. Consortia will control the money and issue contracts for hospital and specialist services. This could increase competition and hinder collaboration in the U.K.
U.K. patients will still have to register with one GP though they will have more freedom of choice of GP, i.e. patients will no longer be restricted to registering with the closest GP to their home. ACO patients will be assigned based on “previous patterns of care” though there will be incentives to use “participating providers”.
What are the take home messages?
We are not the only country muddling through a major health care reform while walking the line between regulations and market forces.
Everyone seems to be seeking the goals of higher quality and lower costs through electronic information upgrades.
Given the similarities between the U.S. and U.K. systems, the charge that Dr. Don Berwick, Head of CMS and a pediatrician, “likes the NHS too much” seems a bit ridiculous.
References:
1. NEJM 364:14, April 7,2011, p.1360-66
2. http://www.hubslist.org, Feb. 1, 2011
3.Mathewson, H.O.. “General Thoughts About General Practice: a medical student’s view of the future of general practice in the United Kingdom.” J Med Educ. 1968, Jan;43(1):36-41.
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