TSR's "Small Incisions" - 9/22/2024
Hot healthcare takes from the Surgeon's Perspective
A rundown of stories from across the healthcare ecosystem — health tech, health policy, digital health, value-based care, and more — with commentary.
Presented by Commons Clinic
This week:
Finding Yourself in the Portrait of a Failing US Health System
Move slow and AI things
I’m sick of “sickcare”
You know you’re doing it right when the AHA is upset
Amazon’s biggest contribution to healthcare
From the Dem Dry Bones Archive: Cascading failure
Mirror, Mirror 2024: An International Comparison of Health Systems (Commonwealth Fund)
Subtitle: “A Portrait of the Failing US Health System.” You can guess what the report found. Cue the yearly news cycle of US healthcare bashing and takedowns. Thumbs meet noses. If you’re looking for anything beyond rehashed talking points and worn thin narratives, look elsewhere. I work in the system every day. I see people doing their best to deliver great care while being asked to do more with less, for less. Many rise to occasion despite crushing inefficiencies and autonomy leeched away by bureaucracy. (To be fair, I see failures too. Poor care born from greed, incompetence, or ignorance.)
I also spend time working with people working on fixes to our problems. Entrepreneurs and innovators trying to make small dents in a large problem — many motivated by deeply personal experiences. They’re dedicated to the idea of something better. We have rent seekers, too. They see a large pie and want their slice (without getting dirty). The next wave of FOMO will carry them off. If you’re upset about the current state of American healthcare, I invite you to push away from the keyboard and roll up your sleeves. We could use the help. Rhetoric only goes so far.
Improving consumer experience with AI in healthcare service operations (McKinsey)
Improving consumer (patient) experience and making administrative functions more efficient and less expensive is the safer (and more appropriate) entry point for AI in healthcare. Granted, it’s not the most interesting — that honor will eventually go to predictive and causal AI applications that allow us to deliver personalized, evidence-based, high value care. That future is farther off. We still lack answers to questions around privacy, black boxes, liability, and hallucinations. Chatbots, conversational AI, and virtual assistants are a middle ground that begins to marry engagement with care delivery. Progress will and should be slow, iterative, and subject to constant oversight — clinical checks and balances. Healthcare moves slowly and cautiously. There are many gray areas, and eliminating the human element is impossible. None of this meshes well with the speed of technological innovation. AI is already expensive and demonstrated ROI is hard to come by. It’ll be no easier for medical applications. But AI will be transformative in healthcare — if we’re patient and intentional.
Disrupting the U.S. “Sickcare” System (MedCity News)
As we approach 2025, I hope we leave the “sickcare system” trope behind. I get it — we do a poor job of preventing illness and focus too much on treating it. You’ll get no argument here. But, despite our best efforts, people can and will get sick. It’s disingenuous to ignore this reality. To suggest that incentivizing “wellcare” alone will fix the problem is an oversimplification. Chronic disease is a complex interaction of social, societal, economic, and medical factors. Transforming the system requires addressing all of them. Until we do, many still need sickcare. This reality shouldn’t be stigmatized, nor should it be seen as a failure. We can make the sickcare system better too. The ideal system of the future will strike a balance between wellcare and sickcare such that a distinction is no longer necessary. Comprehensive, longitudinal, holistic care. Do what’s right for the patient, and do it efficiently and cost-effectively. No sickcare or wellcare. Just care.
The Promise And Pitfalls Of Site-Neutral Payments In Medicare (Health Affairs)
Site-neutral payments? Yes, please. That the same procedure could be reimbursed at different levels depending on where it’s performed is nonsensical. Should we reward HOPDs for higher costs (driven largely by administrative bloat) by paying them more? Switching to site-neutral payments will finally level the playing field and spur (appropriate) migration of procedures to more efficient, cost-effective ASCs. Site-neutral payments can reverse consolidation trends without sacrificing quality of care or access. What’s not to like (assuming you’re not a hospital or health system)? The AHA will continue to fight site-neutral payments — a sure sign they’re a good thing. We are moving toward a future where more care can be safely shifted to the outpatient setting. Fewer towers and sprawling campuses. More micro-hospitals and high-touch care transitioned to the home. Switching to site-neutral payments will further catalyze this movement.
The Four Core Beliefs of Hospital-Employed Physicians (Paul Keckley)
Paul Keckley’s newsletter is an excellent weekly read. Here he points out the growing discontent amongst physicians, driven by increasing administrative hassles and unwelcome clinical oversight. The four core beliefs souring physician-hospital relations according to Paul:
Hospitals spend too much money spent on overhead and exec salaries instead of patient care
Hospitals are poorly run (and ignore physician ideas to run them better)
Hospital payments keep going up while physician payments keep going down
Hospitals need docs more than docs need hospitals, but the balance of power doesn’t reflect this.
I’d argue that these seem core beliefs extend to all doctors, not just employed ones. Keckley argues that these beliefs “may not be fair, objective, or accurate.” I disagree. There is more than a kernel of truth to each of these beliefs with evidence to back them up. “The issue is not whether physician income relative to other professions and average households is high. The issue is about managing physician expectations about their livelihood realistically and practically while improving their clinical acumen as professionals.” On that part, I wholeheartedly agree.
Amazon CEO Vows Leaner Teams Amid Bloat, Ends Work From Home (Bloomberg)
Lost in the kerfuffle about a mandated return to the office is an important initiative around reducing bloat. Per CEO Andy Jassy, Amazon has become plagued with “endless deliberation, unnecessary meetings and layers of approval.” Sounds an awful lot like the administrative bloat that has crept into healthcare. To fix the problem, Jassy has proposed increasing the ratio of individual contributors to managers by 15% and offering a “bureaucracy tipline for employees to raise concerns about unnecessary processes.” I sincerely hope healthcare is taking notes. More frontline workers, less admin layers, and the ability to call out inefficient processes. Yes, yes, and yes. We desperately need similar initiatives on the frontlines. Fewer meetings, more decisiveness, less bloat. Who knew this initiative could be Amazon’s greatest contribution to healthcare? (PS — most of us have no problem showing up to the office!)
Case Study in MSK Value -- Cascading Failure (Dem Dry Bones)
One from the Dem Dry Bones archives (and one I should update and improve for a future TSR post). Inefficient, low value care can often be traced back to a cascade of compounding errors. Poor clinical decisions stacked upon poor clinical decisions. As I discussed during the AAOS Value-Based Care webinar last week, the solution to this problem may be condition-specific bundles. Here I call it MSK 2.0. Getting there won’t be easy, but I believe it’s possible through the integration of technology solutions, holistic care, and a payment model that properly rewards appropriate longitudinal care. This one’s long, but worth revisiting.
Ben Schwartz, MD, MBA
Editor-in Chief, The Surgeon’s Record
Commons Clinic Senior Clinical Fellow
