A New Design for Health Care Delivery

The choice between expanding health coverage and controlling health care costs is a false choice based on a false assumption: that resources committed to health care are used efficiently and effectively. This mistaken notion makes budgeting the key decision and masks a much better alternative. There is ample evidence that better care could be provided to more people at lower cost if care delivery were organized in a more sophisticated fashion.

Today, health care is delivered as it was 50 years ago, when only a limited range of illnesses could be detected and treated. Professionals were organized in silos: nurses in one, various types of doctors in others, and so forth. Grouping by peers afforded the benefits of professional association, such as sharing knowledge, setting standards, and camaraderie — and, for simple treatments, ad hoc, informal coordination across silos was adequate, management of patient information was simple, and piece-rate payment worked fine.

Medical science has advanced dramatically. Once-terminal diseases like AIDS are now manageable and even curable, like many cancers. But care delivery, information, and payment systems have not kept pace with the science. Professionals are still organized in silos, despite the pressing need to integrate their work into coherent processes; information is still fragmented, despite the benefits of holistic views of patients; and payment is still piece-rate even though practitioners are no longer in any real sense independent of each other.

The consequences are destructive. Too little preventative care increases the need for chronic care. Ineffective chronic care for diabetes, heart disease, and depression increases the need for costly acute care of limited effectiveness, which often causes needless harm.

Needless suffering from badly delivered care is tragic; squandering hundreds of billions of dollars is unconscionable. In part because of these inefficiencies, the U.S. spends twice as much on care, per capita, as other developed nations do.

There is an alternative. Some organizations have started emulating outstanding non-health care organizations in actively managing how the process, information, and payment pieces mesh together.

Pioneers have reduced rates of hospital-acquired infections, falls, medication errors, and other complications — symptoms of fragmentation — by 90{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} and more, saving thousands of lives and hundreds of millions of dollars. Ascension Health, the largest Catholic health care system in the U.S., reports pressure ulcer rates in its 67 hospitals 93{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} lower than the national average, birth injury rates 74{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} lower, and patient falls 86{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} lower. Mayo Clinic has reported more than a 50{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} drop in rates of medical injuries to patients in all three of its flagship hospitals. Hospitals that have adopted better processes to deal with 11 common challenges — such as acute heart attacks, patients on ventilators, and early identification of deteriorating patient conditions — championed through the 5 Million Lives Campaign of the Institute for Health Care Improvement have reported improvements in outcomes.

If these stories were national norms, not exceptions, the benefits to patient well-being and to costs would be staggering. But getting there need not be a fantasy. Hospitals, nursing homes, dialysis units, ambulatory surgery centers, and physician offices can improve how they manage preventative, chronic, acute, and urgent care. Medical, nursing, pharmacy, and other professional schools can complement medical science training with training in managing complex work systems, preparing their graduates to be excellent in their roles, and also in tying the pieces together in total systems of patient care. Insurers, employers, and other payers can change their buying patterns to demand and reward coordination and uncompromising process excellence across the entire care continuum.

Since the public sector is the nation’s largest payer, and it supports large medical schools, it can insist on system improvement — and it must.

Steven J. Spear is a senior lecturer at MIT. Donald M. Berwick is president and CEO of the Institute for Health Care Improvement in Cambridge.