Monday, June 15, 2009

Health Care as Systems Engineering

This summer promises a great debate over health care in the U. S. It is pretty sure to be great in the sense of historic or significant; what is not so clear is whether the outcome will be great either in the sense of good and positive, or in the ironic sense ("Great! That's just what I needed!"). One perspective that may help us judge the quality of the debate and the outcome is to view health care through the lens of systems engineering. But since health care deals with the most intimate aspects of human life, ethical considerations also show up at all levels, from individual decision-making to nationwide policy.

It is well known that the U. S. pays more per capita for health care than most other industrialized nations, but by many measures we are not that much more healthy than the other countries are. In other words, we're not getting what we're paying for, if we think that spending more health dollars per person will make everybody that much healthier. Viewed as a system with inputs (health care money and resources) and outputs (people treated by the system), our system does not work as efficiently as it could.

Over the last several weeks I have read of certain parts of the country where the health outcomes per Medicare dollar (which is an easy statistic to obtain) are much better than the national average (e. g. Green Bay, Wisconsin, where President Obama recently spoke on the issue), and other areas where they are much worse (e. g. McAllen, Texas, which a recent New Yorker article identified as in the second most expensive county in the country, measured in Medicare-dollar-per-patient terms). One reason for these identifications appears to be the idea that if we can just figure out what the good places are doing right, we can replicate these successes and do away with whatever bad or evil mischief is going on in the expensive places. How likely is that to succeed?

Atul Gawande, the author of the New Yorker piece, thinks the root problem in McAllen lies in the disconnected, revenue-driven nature of the medical culture there. He says many doctors view their practice as a way of making money, and if you want to practice medicine that way there are few barriers to stop you. By contrast, he cites places like the Mayo Clinic, where doctors on salary receive no incentives for ordering extra tests, and participate in meetings designed to improve patient care systematically by coordinating it to eliminate needless and duplicative tests, among other things. He admits, though, that discouraging the former behavior and encouraging the latter will be a long, tricky process.

I think a key element in the solution, if one can be found, lies in a careful study of incentives and disincentives. Although people can't always be relied upon to do the rational thing, most people will make choices they perceive to be in their own best interest. Of course, perception can be distorted through propaganda and so on, but especially where pocketbook matters are concerned, most people make fairly optimal decisions if given the opportunity to do so. One trouble with health care as it exists today is the same problem I have noticed with the college-textbook market: the people who pay for the goods or services (students or patients) are not the people making the decisions (professors or doctors). Although one doctor quoted by Gawande says allowing patients more of an economic stake in medical decision-making is like relying on "the sheep to negotiate with the wolves," it doesn't have to be that one-sided. If people were in economic control of their own health-care expenditures rather than having to rely on their employer (if they have a job in the first place), I think some way could be developed so that the Mayo-Clinic-type coordinated operations and their lower cost per patient could be packaged to be more appealing in an open market, compared to the multiple-stop-shopping of places like McAllen. The comparison is a little unfair, but think of shopping at Wal-Mart versus going to a third-world village market with its street of shoemakers and street of roasted-goat vendors. The streets full of private vendors are colorful and make for great vacation photos, but if all you want is a pair of shoes you'll go to Wal-Mart.

Of course, efficiency can be carried too far, and if we let even the Mayo Clinics coalesce into one giant monopolistic medical provider, the outcome is likely to be bad. But an appropriate level of market openness in which consumers could see economically efficient, good care for what it is, and choose it, would avoid the coercion and potential for debilitating bureaucracy that so many proposals involve.

Healing is a deeply ethical activity. The oldest known professional code of ethics—the Hippocratic Oath—deals with the ethics of medicine, and many religious leaders such as Jesus made healing an important part of their ministry. The problems Gawande and others have identified when healers start to put money over patient care merely demonstrate that the system, whatever form it takes, must have professionals in it whose philosophy or faith makes healing an end in itself, not primarily a means to wealth. Whatever happens to U. S. medical care after this summer's debate, I hope the designers do not lose sight of the fact that, like doctors themselves, they cannot fix the problem the way you would fix a balky lawnmower engine. All they can do is try to create an environment for people of good will to do even better than they are doing now.

Sources: Atul Gawande's article "The Cost Conundrum" appears in the June 1, 2009 issue of The New Yorker.

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