Looking back over last month’s health-related news, two articles published on The Atlantic’s website stand out to illustrate a tension that has received a great deal of focus in Medicare reform circles, and that seems to be a political sticking point for many otherwise promising cost-reduction strategies. In his September 10th article The Fallacy of Treating Health Care as an Industry, Professor Gunderman of Indiana University criticizes a recent Institute of Medicine (“IOM”) report suggesting that our medical system could be providing better care at lower cost if it could only learn a few lessons from other industries. Professor Gunderman’s critique invokes the specter of mechanical medicine: an “industrial assembly line approach to medicine” where the pursuit of efficient care utterly eclipses the human element, the “communication and relationships” that make the practice of medicine more than just an industry. Similar arguments can be and have been deployed against any resource-sensitive reform of medical practice, as the “death panels” debate from several years ago well illustrates.
While these kinds of human-relationship based critiques of efforts to make medical care more efficient may be relevant in the context of more extreme proposals of medical rationing, they are misguided as applied to recommendations like those made in the IOM report. None of the five recommendations in the report under the “Care Improvement Targets” header seem to pose the existential risk to the practice of medicine that Professor Gunderman suggests. To the contrary, the recommendations focus on providing doctors with tools that enable them to make decisions informed by the best available science and evidence, on encouraging greater coordination of clinical care with population-level health efforts, and on rewarding increased communication and coordination among the physicians and others form a patient’s broader care team.
For an example of precisely this kind of innovative, patient-oriented, efficiency-improving approach to medical care we need look no further than a second article published online by The Atlantic a few weeks after Professor Gunderson’s. Where Surgery Comes With a 90-Day Guarantee tells of an experimental program called ProvenCare implemented by the Geisinger Health Group in Pennsylvania. The program, which like several others around the country charges patients a single, flate-rate fee for all the services surrounding a given procedure or episode of care, has implemented best-practices guidelines for physicians that have resulted in vastly improved outcomes in elective coronary bypass patients. Geisinger is now extending this model of care beyond the relatively straightforward heart procedure to the much more complicated case of perinatal care. Though it is unclear how well such guidelines will function in that context, the key point insofar as we are concerned about the “industrialization” of medicine is that best-practices guidelines and bundled fees do not prevent doctors from forming relationships with their patients or from providing personalized care as Professor Gunderson fears. Rather, the combination of bundled payments and care guidelines may be able to provide doctors with the incentives and the tools to provide better care at a lower cost.