This article was originally published with the title Comparatively Easy.

13 Comments

1. 1. candide 08:40 AM 1/21/10

   Is this a Science site or a political site?
   SciAm doesn't help the name of Science.

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2. 2. joeldooris 09:37 AM 1/21/10

   I've recently come across a heart surgeon in India who is taking an assembly line approach to health care and surgery. Do everything in mass and do it the same way and you can start saving money and lives because of mistakes.
   If I need a kidney transplant I should go to a facility that does only that. A facility that does the same thing day in and day out. They would see ways to improve pt care, as well as ways to save money.
   Come on Henry Ford figured this out at the turn of the century, why don't we do the same now?

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3. 3. dfcrowder 10:23 AM 1/21/10

   As medical director of two western coal companies we have created a program that has reduced our costs per employee to 56% of the 2005 values. Rather than be concerned with discounts we base our program on reducing hospital costs by paying for our employees to have complex care performed at the very best facility for that condition. A Washington, D. C. economist tried to get a grant to develop more value based programs but was told what we were doing was "too easy". The only people who have shown an interest have been the Germans who had me speak at a quality conference last November in Berlin.

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4. 4. Bill Case 11:51 AM 1/21/10

   As someone who has spent time studying various health systems around the world, I can tell you there is a huge basis of reputable world health literature that demonstrates all kinds of ways that health care costs can be reduced.
   
   That is not the problem faced by the American (or other countries for that matter) health care. It is having in place a *system* that allows for the universal imposition of reforms and standards and review. Such systems can be accomplished through either a single payer or a free market system. The U.S. does not have such a system in place yet.
   
   In response to 'candide' above. A science magazine *is* an appropriate place to discuss management systems, particularly if those systems are ultimately science based.
   
   

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5. 5. rajahornstein 02:25 PM 1/21/10

   It's not always so simple to decide on best procedures, especially with mental health care. There are many studies showing CBT (cognitive behavioral therapy) to be most effective with many conditions, but that simple fact covers up huge complexities. There are even stronger studies showing that the nature of the therapeutic relationship is a much stronger predictor of efficacy than the method used. I wouldn't mind if my heart surgeon was a cold son-of-a-bitch or a really compassionate person as long as he followed the best procedure. But I would never see a cold son-of-a-bitch therapist no matter how well he knew how to use CBT. Psychodynamic therapy is much more subtle than CBT and depends much more on the nature of the relationship, and is therefore very hard to test in double-blind randomized studies. Meta-analyses have shown, however, that psychodynamic therapy works almost as well as CBT in the short term, but much better in the long term. In other words, people change in deeper ways, while with CBT the problems come back. So the cheaper, more empirically-based, more "effective" method isn't what it looks like on the surface. The tendency to back CBT as more evidence-based is, in fact, an attempt to ration care that takes longer, is more expensive, requires better-trained clinicians, and works way more effectively.

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6. 6. dfcrowder in reply to rajahornstein 04:40 PM 1/21/10

   The polititians need to back out of reforming our health care system and take their special interests and lobbyists with them. The health care system should be just that, a system. Health care needs to be addressed as an engineering problem applying the same kind of analysis as one would any other complex problem.
   
   We should start with the simplest, most pressing problems and gradually add elements with more unknowns to the equation. The system won't be perfect from the start and may never be perfect but it will beat the hell out of what we have now. As Bill Case alludes there are a lot more solutions in the world than just Canada or the UK. A lot of this is not rocket science.
   
   I am not a researcher, just a retired clinician who was hired to lower cost quickly or significant restructuring of benefits would occur. I wasn't smart enough to know the task was impossible. The urgency carried the caveat something had to be implemented soon. The result was a simple but effective program. I have attended many symposia on care since I started this in 2001. Unfortunately the presentations are academic with very few out there doing anything.
   
   It is time to implement thoughtful solutions and save the retoric for the next levels of complexity. Let us start helping patients (consumers, a word I hate) purchase value based care. No citizen of an affluent, modern nation should lack access to even the most basic healthcare nor should be cost be prohibitive.
   

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7. 7. TTLG 05:07 PM 1/21/10

   Of course science is a good way to optimize health care. Science is simply a feedback mechanism to get the best results. It is already being used in health care. The problem is the definition of "best". For the patient it is simply minimizing suffering. But for the for-profit companies providing and financing health care, best means maximum profits. Which does not necessarily give the best from the patient point of view. Since the money guys are the ones giving feedback (in the form of $$$) to the politicians, guess which form of "best" is going to be legislated?

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8. 8. mikeplacona 06:11 PM 1/21/10

   The utility of a suumative assessment is shaped as much by socio-political factors as by scientific concerns. Historically, programs have been eliminated b/c a study shows performance fails to meet a funders' expectations, which may not be grounded in altruistic values. My question is whether there is any evidence showing such studies increase the likelihhood of providing more effective and meaninful care to the public

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9. 9. Bill Case 12:46 AM 1/22/10

   Some remarks on comments made here. dfcrowder sugests that "The polititians need to back out of reforming our health care system and take their special interests and lobbyists with them." That is wishful thinking. Besides, the establishment of a framework for health care reform has to be put in place before effective reforms can be insituted. Creating the frame work has to be a political decision. Why it has to be political would take pages to argue, but let it simply be said no overarching health care system in the world today was implemented without first taking the political decision to do so.
   
   In response to joeldooris and rajahornstein, most health care systems that already exist are fexible enough to accomodate standards, checklists *and* creative practicing.
   
   One major point that is overlooked by all paricipants in the American health care debate is that once health care enters the public arena, it stays in the public arena. I don't think American national politicans or special interest advocates (left or right) have a full understanding of how much of their political lives are going to be taken up by one health care issue after another -- and scientests will never be able to free themselves from the public debate.

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10. 10. dfcrowder in reply to Bill Case 10:48 AM 1/22/10

    You are of course correct. However the influential input has come from those who will be financially rewarded such as providers and big Pharma not to mention those who view reform as "socialized medicine", a much greater threat than folks dying because of not being able to access care. Sometimes idealism gets the best of me and I think of congress as a rational body.
    
    The group with a weak voice but potentially a big stick has been industry not affiliated with health, yet this group is the source of the money for care. Senior management pays lip service to cost but generally leaves the solutions to human resources. Companies prefer to lobby only about core interests. This philosophy feeds back to the first paragraph.
    
    My companies have the resources to create internal solutions rather than simply accept the status quo. Unfortunately the average person does not have this choice.
    
    Michael Porter at the Harvard Business School has written extensively about value based healthcare. The most concise publication of his was an article from the Harvard Business Review in 2004. T. R. Reid, a NYT Journalist has written a good survey book on systems of care around the world entitled "The Healing of America".

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11. 11. Bill Case 11:39 AM 1/22/10

    You have hit upon something in your second paragraph that as a Canadian I don't understand. I have seen in interviews over that last four or five years, the CEOs of GM, GE, Xerox and many other major firms, complain about the cost of health care. They have complained about the damage the current burden of Employee Health Insurance, legacy health insurance and the international competitive disadvantage that providing Insurance puts on them. Yet they are all absent from the current debate. Why?

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12. 12. hs96dlw in reply to rajahornstein 10:36 AM 1/25/10

    hi rajahornstein, could you provide links to the meta-anayses you mention, i'd be interested to follow these up, thanks.

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13. 13. SpencerTrask 02:32 PM 1/25/10

    Thank you, editors of SA, for spotlighting the potential of CER. We feel compelled to note the contribution of Dr. John Wennberg, his early work in pioneering the first CER database, enhanced by his continuing involvement with The Dartmouth Atlas.
    
    His early scientific work on unwarranted variation has been the progenitor of political interest in CER. Informed patient decision-making based on Wennbergs data led to one of the fastest growing for-profit healthcare management companies, Health Dialog <http://www.healthdialog.com> . HD has indisputably proven that the practical application of CER delivers positive simultaneous outcomes on both patient satisfaction and cost reduction scales - -and we are proud of that.
    
    Our Spencer Trask investor network <http://www.spencertrask.com> were the angel investors for Health Dialog, and the company has delivered infinite returns to investors, insurers and patients alike.
    

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