Chaos and Organization in Health Care

Introduction

Introduction As daunting as the challenges for U.S. health care may be, there is reason for optimism that a delivery system that is much more efficient, reliable, and safe is within our reach. Our optimism is derived not from theory but from our day-to-day work, which ranges from health policy leadership roles to the management of an academic integrated delivery system to hands-on patient care. From this work, we have a frontline view of the good that modern medicine can produce, but also the inef- ficiency, missed opportunities, confusion, and occasional harm. We see the consequences of a lack of health insurance for individual patients and understand the challenges of making coverage for all work. Despite the magnitude and diversity of these challenges, we are optimistic because we believe that they share a common “root cause”— and that this root cause is vulnerable to attack. We in fact see signs of real progress in provider organizations around the country, including our own. Simply put, our assessment is: 䊏 The problem is chaos 䊏 The solution is organization 䊏 The question is how we get there The Problem Is Chaos It would be good news if rising health care costs could be explained by the greed of specific individuals or companies, because then those individuals and companies could be stopped. And it would be good news if disappointing quality and lapses in safety could be blamed on the incompetence of specific physicians, because then those doctors could undergo more training or their licenses could be revoked. “Bad guys” who are greedy or incompetent do exist in medicine, of course, x Introduction but the unfortunate news is that these bad guys play relatively small roles in the creation of our crises in health care. Indeed, the big driver of our problems is an undisputed “good guy”—progress itself, which when imposed on the fragmented U.S. health care system, produces chaos. Let us explain what we mean by progress, fragmentation, and chaos. We are lucky to live in an era during which medical science is racing ahead, producing advances that are easily taken for granted—that is, unless you are a patient or doctor. During our careers, we have seen incurable diseases become routinely curable—like the lymphoma that was diagnosed in September 2006 in Red Sox pitcher John Lester, but eradicated in time for him to join spring training in 2007 and pitch a no-hitter in 2008. Fatal diseases like HIV have become controllable chronic conditions with a surprisingly modest impact on life expectancy . And common diseases have become preventable—like heart attacks, the death toll from which has steadily declined because of the widespread use of medications that control blood pressure and cholesterol. We are not among those who wax nostalgic for the simpler and less costly health care of a generation ago. To be a doctor today is to know there is virtually always something you can do for a patient, no matter how sick he or she might be. We like that. But to be a doctor today—or a patient—is to be overwhelmed by an explosion of new knowledge. That explosion produces multiple options for testing and treating conditions for which there were none just a few years ago. The knowledge explosion also means that giving complex patients state-of-the-art care requires multiple physicians with highly specialized expertise. These physicians need to communicate with each other, and ideally, should develop clear game plans with patients and their families. Unfortunately, this explosion of knowledge has gone off within a health care delivery system that is poorly prepared to help physicians make the best decisions or work effectively together. Most office visits in the United States are at small practices with one or two doctors, who write prescriptions on prescription pads and store notes in paper charts. These doctors work hard, but they work in isolation, struggling to stay up to date on the best ways to help their patients. Many settle for a more modest goal: just staying one step in front of their patients, who often bring printouts from the Internet to office visits. Introduction xi An even greater challenge for these isolated physicians is providing coordinated care for their patients—a goal that requires knowing what other doctors are doing and saying. A generation ago, these physicians might have seen each other in the...