By J. Deane Waldman
This is the second Part of a three-part series on the U.S. healthcare system. In Part 1, we came to understand the causes of problems in our healthcare system, not just the obvious symptoms that everyone complains about: rising costs, bad outcomes and errors; medical malpractice; and personnel shortages. We know that to cure anything, you must treat the causes not the symptoms. To cure a headache, you remove the tumor rather than just give the patient morphine.
Most of us feel the need to assign blame and take aim at rich, uncaring insurance companies; wealthy, arrogant doctors; or even wealthier, Ferrari-driving medical negligence attorneys. Let me help put the blame squarely where it belongs: with the system, not its parts.
The reason we experience what we do from healthcare is because the system does not work. As presently constructed, it cannot work. That system is plagued with internal consistencies and contains a malprocess in place of an effective malpractice system. Lacking an effective decision-making process, it makes bad decisions.
IT'S THE SYSTEM, STUPID!
Internal Contradictions and Inconsistencies
The healthcare system is replete with contradictions under which both white coats [providers] and the suits [administrators; managers] must try to function. Academic and business people believe that health care is or should be regulated by the market (supply and demand) while the Public has been told over and over that health care is an inalienable right.
Everyone knows that the more information available, the better our health care: fewer errors; more consistent and less costly care; and better quality. Yet government regulations like HIPAA (Health Insurance Portability and Accountability Act) place a higher value on security and confidentiality that on quality or error prevention.
The following scenario is real: an everyday occurrence. A medical receptionist is asked to FAX health information to another doctor. By HIPAA rules, she is forbidden to read the FAX. According to the Patriot Act, she is required to read the transmission. What should she do?
Many hospitals are required by law to provide care to certain patients, even if the hospital never gets paid. Imagine a business that is required to give its services away for free. What games would it have to play, what tricks must it use to stay in business?
The care a patient receives is a summation of decisions made by medical providers, health care managers and healthcare regulators. Yet the only group held responsible for the outcomes are the providers.
Contradictions and inconsistencies abound.
Medical Malprocess
There is a complex structure built to deal with bad outcomes in health care called medical malpractice or med-mal. What do we want med-mal to do? Vengeance? Weeding out "bad apples" (incompetent providers)? No, we want two things from any such system: 1) help when injured during medical care, and 2) learning from bad outcomes to do better in the future.
Our current system is an adversarial process in court where the injured patient receives compensation only if a provider, one with a deep pocket, is proven negligent. Furthermore, the med-mal approach shrouds the details in secrecy, preventing wide sharing and subsequent learning. Med-mal is a malprocess: a "bad system" that does not deliver what it is supposed to because it cannot, as presently constructed.
A process is "a series of steps taken in order to achieve a particular end." The current practice of medicine is a process that fails to achieve the results we want. Therefore, healthcare as a whole is a bad (mal) process.
Flawed Decision-making
To accomplish anything, from opening a door to buying a hotdog to getting your hernia fixed, you have to make decisions. The better the decision, the better the outcome. The process of making good decisions requires two elements lacking in healthcare: evidence and feedback.
You need evidence in order to know that what you decided will accomplish what you want. Feedback is necessary to tell you what actually happened so you can do better the next time.
In healthcare, there is a strong commitment to evidence-based decision-making but only among providers. Managers, regulators, and legislators depend on logic and have no obligation to prove in advance that what they decide will work.
For providers, feedback is weak and often prevented by med-mal secrecy, confidentiality rules, and security protocols. For healthcare managers, regulators and legislators, there is no feedback or consequences - to them - from the decisions they make. How can anyone learn to do better if they do not get feedback?
Conclusion, Part 2
As long as we focus on the big, bad insurance company, the drunken nurse or the lazy, incompetent bureaucrat [all rarities], we can ignore the real culprit: a system that was never intended to handle modern medicine and therefore, does a very bad job of delivering good health care. Details on all of these issues can be found in the forthcoming book Medical Malprocess, and at www.thesystemmd.com. In Part 3, we consider what we can do to create a good (bene) process.
Note: Every statement made herein can be supported by evidence: they are not simply the author's opinion or bias. For examination of these references, feel free to contact the author.
By J. Deane Waldman, MD MBA
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