Aug 13, 2009

How Do They Do That? Low-Cost, High-Quality Care in America

In middle school, the goal was to be cool. Picking out the misfits was easy. They were the ones who carried tons of books, wore clothes that never seemed to fit well, and had no idea that "Baby One More Time" was a song sung by the newly popular Britney Spears. I was one of those. I spent an embarrassingly great amount time studying how to become cool and decided that being cool meant knowing exactly what was "in" and having a cool attitude. How did I come to this conclusion? I picked out some of the coolest and most popular kids at school and asked, "How Do They Do That?"

Just yesterday, Atul Gawande, Don Berwick, Elliott Fisher, and Mark McClellan, published an Op-Ed in The New York Times. In the Op-Ed, the four weigh in on the current health care reform dialogue: raising taxes or rationing care in order to expand coverage and control the rising, nation-crippling health care costs. The take home message of the Op-Ed is that raising taxes or rationing care are not the only alternatives to achieving health reform. Why not try redesigning how health care is delivered so that it is both low-cost and high-quality?

This is the same situation as the misfits in middle school striving to be cool. What we as a nation need to do is identify these high-performing examples and ask, "How Do They Do That?"

This is an exploration that Atul Gawande, Don Berwick, Elliott Fisher, and Mark McClellan have already started. Data from The Dartmouth Atlas, a research initiative hosted by The Dartmouth Institute for Health Policy and Clinical Practice that uses Medicare claims data to document variations in how medical resources are distributed and used in the United States, was used to identify these high-performing examples. Out of the 306 Hospital Referral Regions (HRRs), regional health care markets for tertiary medical care, across the US, 74 high-performing regions were identified. (Click here to see the Medicare spending in your HRR). What does high-performing mean? These regions have per capita Medicare costs that are low or markedly declining in rank and have above average quality based on federal measures.

Out of these 74 high-performing HRRs, teams of hospital executives, physicians, and local leaders from 10 geographically different regions were invited to Washington, D.C., on July 21st to tell us, "How Do They Do That?" These HRRs included: Asheville, North Carolina; Cedar Rapids, Iowa; La Crosse, Wisconsin; Sacramento, California; Sayre, Pennsylvania; Portland, Maine; Everett, Washington; Temple, Texas; Richmond, Virginia; and Tallahassee, Florida.

The stories these 10 teams shared with us that day were truly remarkable. If the other 232 HRRs could perform like these high-performing examples, we'd be in good shape.

The most interesting finding of the day was that there is not just one way to become a high-performer. Some of these HRRs have one dominant health system where physicians are salaried (Scott and White Hospital and Clinic), while other HRRs had highly competitive systems sharing the market (Sacramento, CA).

Some of the major themes from the day were using data to inform change (The Op-Ed specifically refers to the number of CAT scans in Cedar Rapids), using lean/six sigma and other waste reduction/process improvement strategies in their daily operations, creating strong community ties and being accountable for the health of the region, training and creating opportunities for physician leadership, building a patient-centered culture, and continuous improvement. All of the HRR teams were surprised to find out that they were high-performers and acknowledge that they still have plenty of room for improvement.

Now that we've found these great examples, the cool kids of the health care middle school, we need to continue to ask, "How Do They Do That?" and follow their lead in redesigning health care to create a high-performing and healthy nation. Doesn't that sound like a great alternative?