When we entered the world of health care improvement as our life’s work, we didn’t ask for the burden we now bear. We did not ask to be responsible for rescuing health care.
But, here we are, and, as intimidating as the fact may be, that burden is ours. Our nation is at a crossroad. The care we have simply cannot be sustained. It will not work for health care to chew ever more deeply into our common purse. If it does, our schools will fail, our roads will fail, our competitiveness will fail. Wages will continue to lag, and, paradoxically, so will our health.
The choice is stark: chop or improve. If we permit chopping, I assure you that the choppi ng block will get very full – first with cuts to the most voiceless and poorest us, but, soon after, to more and more of us. Fewer health insurance benefits, declining access, more out-of-pocket burdens, and growing delays. If we don’t improve, the cynics win.
That’s what passes the buck to us. If improvement is the plan, than we own the plan. Government can’t do it. Payers can’t do it. Regulators can’t do it. Only the people who give the care can improve the care.
What’s the strategy? Let me show you one. I owe much of this to my friend and colleague, Andy Hackbarth, who has been collaborating with Joe McCannon, others, and me for much of the year to develop a set of lenses clear enough to let us see the pathway to success.
We began with work far from health care – the work of a Princeton economist and environmental expert named Robert Socolow. Professor Socolow published an important article in 2004 in Science magazine, trying to answer a very important question: “What is the way to slow the rate of atmospheric carbon production enough to avert catastrophic carbon levels in the future.”
Here is his answer: “There is no way.” That is, there is no singleway to do it. Automobile emission control can’t do it. Solar power can’t do it. Conservation can’t do it. The only way we can do it is to do, not one thing, but everything. When I read Socolow’s article, I thought instantly of Göran Henrik’s answer to me when I asked him a few years ago how Jönköping County in Sweden was achieving such pace-setting results in total health system performance. Göran said, “Here’s the secret: We do everything.”
“Do everything” – that’s Socolow’s answer to the global warming problem. Luckily, nothing more than everything is necessary, and, unluckily, nothing less than everything is sufficient. Socolow diagrammed “everything” as what he called, “wedges.” In his chart, the lower line is the line of “sustainability.” It shows the highest levels of atmospheric carbon that do not lead to runaway warming. It’s the goal. The top line is the “business as usual” line; it shows how fast carbon levels rise if we stay on the current course.
The “wedges” – Socolow proposes 15 of them – 15 changes that affect carbon output – fill what Socolow calls the “sustainability triangle.” The “wedges” framework looks a lot like a strategic plan, or at least a system of strategic goals, whose cumulative effect – all together – is a sustainable level of carbon, so that we don’t cook Planet Earth.
Solving the health care crisis has wedges, too. We don’t have ascrystal clear a target – a sustainability level that works for total US health care spend – but for sure our business-as-usual line isn’t it. Pay on that line over time, and schools suffer, roads suffer, museums suffer, and private consumption suffers because, as Tom Nolan said years ago, “It’s our money.” It is all wages.
Now, I probably owe you an apology for talking about costs. I know that, among the important dimensions of quality — safety, effectiveness, patient-centered care, timeliness, efficiency, and equity — I am not sure any of us would have chosen “efficiency” — the reduction of waste — as our favorite. It’s not my favorite. Nonetheless, it is the quality dimension of our time. I would go so far as to say that, for the next three to five years at least, the credibility and leverage of the quality movement will rise or fall on its success in reducing the cost of health care — and, harder, returning that money to other uses — while improving patient experience. “Value” improvement won’t be enough. It will take cost reduction to capture the flag. Otherwise, “cutting” wins.
But, I am not going to apologize. That’s because if you are a student of lean thinking or quality, itself — if you have taken the time to study the work of Noriaki Kano, or Jim Womack, or Taichi Ohno, or Dr.Deming, you know that great leverage in cost reduction comes directly — powerfully — exactly from focusing on meeting the needs of the person you serve. “Waste” is actually just a word that means, “Not helpful.” So, that initial wave of reaction — “Who wants to work on efficiency” — is actually off the mark. In very large measure, improving care and reducing waste are one and the same thing.
How much cost reduction? Well, If we look to Europe for ideas, then a target of, say, 12% of our GDP, far below our current 17% would look plausible. If you want to stay at home for signals, find the lowest cost quartile of American health can economies – hospital referral regions or HRRs — and we’d be somewhere in the neighborhood of 15% of GDP. Or, maybe that looks tough, and you’d be more comfortable if health care began to behave just as well as, but no better than, the rest of the economy — that is, rising in synch with the GDP, itself, and just staying where it is — 17% or so.
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