TW: In this third and final part of this series on the Gawande article, he provides examples of "positive deviancy" being practiced by health care providers. The key being understanding the sometimes perverse incentives which drive health care treatments combined with a willingness and ability to confront those incentives if needed.
From New Yorker:
"Fixing this problem can feel dishearteningly complex. Across the country, we have to change skewed incentives that reward quantity over quality, and that reward narrowly specialized individuals, instead of teams that make sure nothing falls between the cracks for patients and resources are not misused. President Obama, I’m pleased to say, committed to making this possible in his reform plan to provide coverage for everyone. But how do we do it?
Well, let us think about this problem the way Jerry Sternin thought about that starving village in Vietnam. Let us look for the positive deviants.
This is an approach we’re actually familiar with in medicine. In surgery, for instance, I know that I have more I can learn in mastering the operations I do. So what does a surgeon like me do? We look to those who are unusually successful—the positive deviants. We watch them operate and learn their tricks, the moves they make that we can take home.
Likewise, when it comes to medical costs and quality, we should look to our positive deviants. They are the low-cost, high-quality institutions like the Mayo Clinic; the Geisinger Health System in rural Pennsylvania; Intermountain Health Care in Salt Lake City. They are in low-cost, high-quality cities like Seattle, Washington; Durham, North Carolina; and Grand Junction, Colorado. Indeed, you can find positive deviants in pockets of most medical communities that are right now delivering higher value health care than everyone else.
We know too little about these positive deviants. We need an entire nationwide project to understand how they do what they do—how they make it possible to withstand incentives to either overtreat or undertreat—and spread those lessons elsewhere.
...First, the positive deviants have found ways to resist the tendency built into every financial incentive in our system to see patients as a revenue stream. These are not the doctors who instruct their secretary to have patients calling with follow-up questions schedule an office visit because insurers don’t pay for phone calls. These are not the doctors who direct patients to their side-business doing Botox injections for cash or to the imaging center that they own. They do not focus, the way business people do, on maximizing their high-margin work and minimizing their low-margin work.
Yet the positive deviants do not seem to ignore the money, either. Many physicians do, and I think I am one of them. We try to remain oblivious to the thousands of dollars flowing through our prescription pens. There’s nothing especially awful about that. We keep up with the latest technologies and medications in our specialty. We see our patients. We make our recommendations. We send out our bills. And, as long as the numbers come out all right at the end of each month, we put the money out of our minds. But we do not work to insure we and our local medical community are not overtreating or undertreating. We may be fine doctors. But we are not the positive deviants.
Instead, the positive deviants are the ones who pursue this work. And they seem to do so in small ways and large. They join with their colleagues to install electronic health records, and look for ways to provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don’t miss their mammograms and pap smears or their cancer follow-up. They think about how to create the local structures and incentives to make better, safer, more appropriate care possible.
...one such positive deviant...He’d invested in an imaging center with his colleagues. But they found they were losing money...The answer, they realized, was to order more imaging for their patients—to push the indications where they could. When he realized what he was being drawn to do by the structure he was in, he pulled out. He lost money. He angered his partners. But it was the right thing to do.
I met another positive deviant, a thoracic surgeon named Dr. Mathew Ninan, who joined a group of pulmonologists, surgeons, and oncologists in Memphis to change the quality of care for lung-cancer patients in their city. “Our approach is simple,” he told me. “We will see every patient regardless of insurance status. We will make every attempt to see patients jointly in one visit. We will discuss every new patient that we see in a multi-disciplinary format on the same day and decide on a plan of treatment. We will follow every patient to track whether they receive the right treatment. And we will enroll as many patients as we can in clinical trials dedicated to improving lung-cancer care.”
To insure that unnecessary costs are avoided, they took yet further steps. The toughest was that the surgeons agreed to do no operations on lung-cancer patients unless the pulmonologist and oncologist agree that it is indicated. This is radical. “I have had to swallow my ego repeatedly to stick to this principle,” he said. Sometimes he’s had to persuade them an operation was best. More often, however, they persuade him to drop his plan and with it the revenue. And he did—because it was the right thing to do.
No one talks to you about money in medical school, or how decisions are really made. That may be because we’ve not thought carefully about what we really believe about money and how decisions should be made. But as you look across the spectrum of health care in the United States—across the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine.
...Along the way, you will sometimes feel worn down and your cynicism taking over. But resist. Look for those in your community who are making health care better, safer, and less costly. Pay attention to them. Learn how they do it. And join with them.
If you serve the needs of your patients, if you work to ensure that both overtreatment and undertreatment are avoided, you will save your patients. You will also save our country. You are our hope. We thank you"
http://www.newyorker.com/online/blogs/newsdesk/2009/06/atul-gawande-university-of-chicago-medical-school-commencement-address.html
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