Are Ordeals a Viable Way to Improve Health Care Delivery?

By Thomas W. Feeley

We constantly hear that the American health care system is broken and badly in need of repair. Our system provides poor value in that our per capita spending is more than any other nation in the world and yet we do not have the best health outcomes.

For many years, incremental solutions have been brought forward as solutions to our health care delivery problem. Approaches such as using evidence-based guidelines, focusing on patient safety, requiring prior authorization of expensive procedures, making patients pay as customers, adopting lean, six-sigma, electronic records, and using care coordinators, to name just a few, have failed to solve the problem.

It was therefore with great interest that I attended the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics’s conference, “Ordeals in Health Care: Ethics and Efficient Delivery” at Harvard Law School earlier this month. I am always interested in hearing new approaches to efficiency in health care delivery and was intrigued by the offering.

The premise of the event was that economic ordeals, interventions that deliberately make access to products or services more difficult, can improve resource allocation. Research in developing economies suggest this approach works in certain health care situations. The question raised by the scholars leading the event postulated that making it difficult for patients to schedule an appointment with a specialist might discourage patients who could be adequately cared for by a less specialized provider. Similarly, they questioned whether putting brand-name medications at the bottom of a long list of options on clinicians’ computers might encourage them to prescribe a less expensive generic option listed closer to the top. They also proposed that requiring time-consuming paperwork by clinicians to prescribe expensive drugs could limit their use.

I am physician who practiced clinical medicine for over 40 years before joining the faculty of Harvard Business School. While I listened with interest to the opening of this conference, I was appalled that anyone would look at health care in the United States and ask that our patients endure more ordeals than they currently face.

For the past 20 years I worked with patients with cancer. This life threatening condition, which is the second leading cause of death in the United States, results in patients already undergoing many ordeals. They must first get the right diagnosis. They then need to gain access to the right provider in the right setting. They then face weeks to months of intense, stressful treatments, frequently with unpleasant side effects. Would adding to these patients’ existing ordeals improve their outcomes or control the costs of their care? I doubt there is a clinician or cancer patient in the world who would think that makes sense.

To the contrary, there is considerable evidence that stress can adversely affect patients with cancer. People who have devoted their lives to caring for other human beings are constantly trying to reduce the stresses and burdens of illness, not add to them. The same can be said of clinicians who seek to address most other conditions patients develop in the course of their lives.

What about the concept of adding to the administrative burden of today’s physicians to improve health care? Physician burnout is a real issue with as many as one in three physicians experiencing burnout at any given time. This is often primarily due to the inherent stress of caring for other people. However, recent changes in administrative requirements make caring even more difficult with increased paperwork and less satisfaction. Electronic records have made care more challenging rather than easier. Burned out physicians make more errors, are less productive, decrease their work hours, and retire prematurely.

So why would society want physicians to have more ordeals to improve the health care system? Before we begin to think about whether intentional ordeals could be productive, we need to relieve many of the burdens imposed on physicians and other providers. To do otherwise would be unproductive.

So if ordeals are not a good idea for patients and providers, how do we improve the health care delivery system? As I have said, incremental solutions have not improved our delivery system, and we have a costly and inefficient system with outcomes that are less than we would expect. One approach we have been intensely evaluating at Harvard Business School is the concept that if we make value for patients the goal of health care, we can address many of the problems faced by our delivery system.

This approach, first developed by University Professor Michael Porter and now being tested around the world, calls for a major redesign of how health care is delivered. Value for patients is the best outcomes at the lowest cost, and is achieved by organizing care first around the conditions that patients have, rather than the specialties of the doctors who treat them. This puts the patient at the center.

We then need to measure the outcomes of those conditions that actually matter to both patients and their doctors. Our cost measurement needs to focus on the cost to treat a patient with a condition, rather than the charges we create for every visit and treatment provided. The health care system needs to then move away from our current fee-for-service payment system and pay for good outcomes through bundled or capitated payments. We need to eliminate expensive, redundant services, and expand the development of centers of excellence. Finally, we need a robust information technology platform to aid in communication, education, measurement, and reimbursement of a new delivery system.

In order to do this we will need the help and support of the legal community since some of what we need to do is currently constrained by laws and regulations that address our existing delivery system. We need to break down barriers to competition, facilitate measurement, and simplify reimbursement by working together to make value for patients our mutual goal to improve the US healthcare delivery system.

Thomas W. Feeley is a Senior Fellow at Harvard Business School and Professor Emeritus at The University of Texas M.D. Anderson Cancer Center in Houston, Texas.