Big Med

This week’s New Yorker magazine has an article titled “Big Med” by Dr. Atul Gawande.  (There is a link to the article under Interesting Articles/Information to the right).  It is about how restaurant chains combine quality, cost control and innovation.  His question is “Can health care do the same?”  Dr. Gawande is a surgeon at Brigham & Women’s Hospital in Boston and he has written several books about healthcare quality and cost control. 

Big Med talks about how restaurant chains, specifically the Cheesecake Factory have been able to deliver high quality meals at a reasonable cost across the country to more than 80 million people per year.  On the surface, it seems ridiculous to compare the US hospital system to the Cheesecake Factory but after reading this article, one might not think it is so far-fetched. 

Dr. Gawande says “in medicine too, we are trying to deliver a range of services to millions of people at a reasonable cost with a consistent level of quality.  Unlike, the Cheesecake Factory, we haven’t figured out how.  Our costs are soaring, the service is typically mediocre, and the quality is unreliable.  Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.”

 He writes about how medicine in the US is changing; most physicians used to be self-employed but now only about 25% are. The rest are employees of large health systems.  He says “Historically, doctors have been paid for services, not results…we’ve generally been paid for what we do, whatever happens”.  Now most health insurers are linking cost reduction and quality improvement targets to financial goals:  “They want to create Cheesecake Factories for healthcare”.

This article devotes a lot of words to the business side of healthcare.  I found this quite interesting because I have a business background, but others might find it long-winded.  Basically the theme is that by getting scale through consolidation of healthcare systems, procedures and costs, medical care can be standardized, leading to lower expenditures and better outcomes. 

Dr. Gawande also discusses how he selected the surgeon for his mother’s knee replacement surgery.  This was quite interesting and informative.

His view is that “We’ve let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous.  The Cheesecake Factory model represents our best prospect for change.  Some will see danger in this.  Many will see hope.  And that’s probably the way it should be.”

I am in the camp of seeing hope in this model.  I would prefer evidence- based treatments and standardized care with substantial oversight on treatment protocol.  Unfortunately, as I contemplate surgery, I am in the old model of non-standardized care, hoping not to be in the lower quartile of patient outcomes.