American health care is obsessed with more.
But the industry is beginning to realize that more isn't always what’s best for patients. Dr. Atul Gawande, a globally respected surgeon, recently pointed out the harm that can come when physicians do more, particularly for patients near the end of their lives. And Charles Munger, vice-chairman of Berkshire Hathaway and partner to Warren Buffett, called health care’s fee-for-service payment model dysfunctional because it rewards doctors for performing more procedures, not for achieving better outcomes.
In the pursuit of more, American health care has too often missed the mark on better. And to become better, health care must change its culture, its financial structure and how we educate our nation’s medical students.
Dr. Gawande, a best-selling author and one of the leading physician voices in the country, took on this issue during this year's Stanford Medical School annual Tseng Lectureship. At the end of his keynote address on the medical needs of the elderly and the terminally ill, I participated in a panel discussion along with him and Munger on the future of America's failing health care system.
What both Munger and Dr. Gawande said was remarkably different from what I’d heard at similar events from other panelists in the past. Together, they reinforced my optimism that true change in health care is coming. Perhaps soon.
With the expansion of coverage through the Affordable Care Act and the health insurance exchanges, American health care has reached a “strategic inflection point.” And with it, we can expect physicians to focus more on quality outcomes, less on the quantity of procedures they perform.
After all, when a leading academic and clinically active surgeon from Harvard like Dr. Gawande highlights the need to improve quality of life for the elderly, rather than new medical technologies, something feels very different. And when a prominent businessman like Munger describes the traditional fee-for-service payment model as an impediment to solving the nation's health care challenges, we can assume that a pay-for-value model is no longer just a pipe-dream for policy wonks. And when an audience of academic faculty, trainees and aspiring doctors nods in agreement, change is likely to happen sooner than later.
The Problem of Confronting Age With More Care
In 1950, America’s average life expectancy was 68 years. Today, it’s 79. This development is partly a result of billions of dollars and millions of research hours spent on new drugs and procedures that extend life – even if only by weeks or months. Many celebrate it.
Dr. Gawande has a different take. He stressed that for most people, there comes a time when the quality of those years becomes more important than the absolute quantity.
From a societal and regulatory perspective, Dr. Gawande pointed out that Americans embrace safety and fear injury. This is particularly true for adults making choices for their elderly parents. However, research shows that older adults are less concerned with safety and more worried about losing their autonomy.
When my 90-year-old aunt experienced several "minor" side effects from her medication, she brought her bag of medications to her doctor. He told her that if she could stand the side effects, she would likely live a little longer – maybe a few extra months or even a year. After the visit, she called me for advice. It was the first time in her life when she wasn't sure the painful side effects were worth it.
The desire to consider quality of life over quantity can conflict with some of the practices of modern medicine. But it’s entirely consistent with the core values of the profession: first do no harm – and always respect the patients’ choices.
Often, medical care requires physicians to make people feel worse today, so that they’ll feel better tomorrow. For instance, patients frequently are in pain for days after a complex surgery. But, of course, they undergo the operation so they can be pain free for years to come. It’s usually a good trade-off.
In some cases, however, a positive outcome is unlikely. When that happens, the calculus changes. Many decide what's most important is feeling as good as they can today. This is the foundation for palliative care: make today the best day possible, even if that means forgoing the most aggressive treatment available.
And contrary to what many might assume, research suggests the decision to focus on today over tomorrow may actually increase both the quantity and quality of a person’s remaining life. In one study, patients with stage IV lung cancer who stopped chemotherapy sooner and entered hospice care earlier experienced less suffering at the end of their lives – and lived 25 percent longer than those who received the usual oncology care.
Palliative approaches that focus on today, not tomorrow, were politicized and shunned by some in the past. Critics said the entire field represented "death squads." But with people like Dr. Gawande at the forefront of this important conversation, it’s clear a shift is taking place.
The Problem Of Paying More For Doing More
Like many successful business leaders, Charles Munger is a great storyteller. So, to demonstrate the perverse economic incentives underpinning American health care, he recalled a story about rattlesnakes.
In a small Texas town, the local government had an idea to combat the growing snake problem. They offered a bounty for every dead rattler brought into city hall. The next thing they knew, everyone in the town was raising rattlesnakes.
This well-intentioned incentive didn't solve the rattlesnake problem, but it does well to demonstrate the perverse consequences created by health care’s fee-for-service model.
As an example, Munger talked about one surgeon who was known for removing normal gallbladders. Having been caught doing what most surgeons would describe as inappropriate surgery, what was his response?
The doctor said taking out a normal gallbladder was a reasonable way to "prevent disease." He said he was helping his patients avoid the dangers of a possible rupture. However, this almost never happens in people with normal gallbladders.
Of course, this isn't the only instance of a doctor abusing the system. In cities like Miami with a surplus of doctors and facilities, we see twice the number of tests, procedures and hospitalizations than in other communities. Whenever a group is paid to do more, not better, the outcome isn't hard to predict.
The Future Of Achieving More With Less
Health care’s long-running obsession with more – and its tendency to overlook better – won’t be easy to reverse.
Going forward, we’ll need to figure out how to have the right conversations with patients, so they can decide if and when to shift their preferences from quantity to quality of life. And we still need to determine how best to pay physicians and hospitals if we want to avoid substituting one set of unintended consequences for another.
Despite the uncertainties, something big is happening in American medicine. Hearing Dr. Gawande and Mr. Munger speak that night – offering solutions that would be labelled radical even a decade ago – I’m optimistic change will occur. As more people demand autonomy later in life – and as medical schools teach the importance of understanding their needs – alternatives to the traditional health care model will expand.
With a push from the Federal government and insurers to move from fee-for-service to value-based payments, physicians will create innovative and improved approaches to clinical medicine. I’m not sure how rapidly this will happen but I’m confident that when it does, patients and their families will be the ones who benefit most.
