Senior Fellow Henry Aaron reviews the new book, Chaos and Organization in Health Care (MIT Press, 2009), by Thomas H. Lee and James J. Mongan.
Physicians often complain that they are underrepresented in discussions of health system reform. This book shows why they are right. Tom Lee and Jim Mongan, both physicians, have written what is, perhaps, the single most informative and absorbing examination of what is wrong with the U.S. health care system and what to do about it. Their book is laced with compelling anecdotes and real-life cases. It is written with clarity and passion. Most importantly, it is at once a practical guide to action and a warning not to expect quick results. No reader of this book can fail to understand that health system reform is the work not of one presidential term or even one presidency but of a generation.
The message is straightforward. The hurtling advance of biomedical science has vastly multiplied the range of beneficial services that health care providers can deliver and are delivering. Still, what is being delivered is tragically short of what is possible. The financing and organization of health care delivery were formed in an age when one doctor could master most of medical knowledge and supervise the diagnosis and treatment of most conditions. If consultations were needed, they could be arranged on an ad hoc basis.
That age is dead and gone. Advancing science has pushed the range and complexity of health care far beyond the capacity of any one person to master. Norms emphasizing physician independence that evolved when such mastery was possible have become dangerous. Forced to deal with the mounting responsibilities and capabilities generated by modern medical science, fragmented health care delivery is prone to error and incapable of effectively mobilizing available technology.
The solution that Lee and Mongan prescribe is team-based delivery of care, supported by modern information technology and backed up by extensive research on effectiveness, careful monitoring of results, and alignment of incentives with goals. A few systems are moving toward that ideal: Mayo Clinic, Intermountain Healthcare, the Geisinger system, and, surprisingly to many, the Veterans Health Administration. Even they, however, do not yet have the information base necessary for providing the best care that available techniques make possible.
Unlike many commentators who describe an ideal system and then neglect the obstacles to its realization, Lee and Mongan start with health care arrangements as they exist, describe the myriad obstacles to change, and try to identify practical ways in which that system could be made to evolve into a better one. The key words in the preceding sentence are “evolve” (not “transform”) and “better” (not “ideal”).
The reason they adopt this evolutionary (as opposed to “revolutionary”) perspective is rooted in their own experience within one of this nation’s premier, but (until recently) quite traditional, health systems—Partners HealthCare—which consists of various hospitals, clinics, and affiliated physicians. Nudging top-flight physicians, steeped in traditional medical practice, into the collaborative team approach is hard and it is slow. Getting highly respected practitioners to subject themselves and what they do to observation, quantitative measurement, and the criticism of others is very hard as well as slow. The book contains a long section that details Partners’ efforts to encourage this evolution.
Lee and Mongan examine various proposed transformational changes, point out the promise that each holds, and then deflate exaggerated claims about their effectiveness. These “unmagic bullets” include passionately advocated beliefs of the left and right. Is increased patient choice the road to high-quality health care? Well, not really, because free patient choice of providers actually aggravates fragmentation; and furthermore, patients aren’t very good judges of quality. Can market forces control spending growth? Nope—patients just don’t like and won’t join plans that expose them to high costs during serious illnesses, and patients are not very effective at using the information they are provided. How about a single-payer system? It can cover everyone, but will it improve the quality of care and hold down spending? Maybe, but there is nothing in single-payer plans here (Medicare) or abroad to suggest that a single, government-managed plan will necessarily reduce fragmentation or slow spending growth. Will more preventive care lower spending growth? Countless studies say “no,” because prevention costs as much as it saves. And, oh yes, the doctor’s favorite—is physician autonomy the key to high-quality health care? Nope; in fact, physician autonomy is the problem, not the solution.
On perhaps the most important issue—will the reorganization that the authors recommend reduce costs as well as improve quality?—they are not entirely clear, and, I believe, for good reasons. The issues are analytically complex, and the results depend not on technical matters but on political decisions no one can anticipate. On page 235, they label the view that higher quality will reduce costs a myth: “We really wish this myth were true. …The harsh reality is that better quality generally means higher costs, not lower ones.” Yet six pages later, they write on the promise of payment reform that “if providers were effective, efficient, and creative in their care, they could share in the substantial savings that result from averted hospitalizations.”
How can both statements be true? The answer, I believe, is that the current system contains considerable duplication and waste, whose elimination could save billions of dollars and sacrifice nothing. Some of it arises from the disorganization that Lee and Mongan target and some from poor information or none at all about what methods of diagnosis and treatment work best. Many of the savings from improved organization and information will accrue slowly, for reasons Lee and Mongan emphasize—it took twenty-five years for the use of beta-blockers and aspirin after coronaries to become routine, although the evidence was clear and the intervention was cheap. Billions saved, over an indeterminate period, in a system that is growing more than $100 billion a year may be hard to detect. Furthermore, far more is spent on services that are beneficial, but only marginally so, than is spent on pure waste. Curbing this spending would mean that someone—elected officials, insurers, doctors, hospital administrators—would have to utter the ultimate political obscenity: rationing. Furthermore, even as increased efficiency lowers low- and no-benefit spending, it will raise outlays to provide care to those who should be treated but aren’t.
Lee and Mongan are instructive even with this bit of perhaps unintended ambiguity about the impact on cost of reforms they describe and prescribe, because it mirrors the awkward complexity of the cost challenge that health care presents to this nation.
My bottom line is simple. This book is fun to read, enormously instructive, and devoid of ideological cant. Read it!