American Health Care’s “Original Sin”

Posted on | May 17, 2017 | 2 Comments

Mike Magee

As a young surgeon in rural New England, serving farmers and mountain people on the Massachusetts/Vermont border, my growing interest in health management was fueled by two luminaries – one 90 miles to the north and the other 90 miles to the east. One was fast at work mining Medicare databases to expose high geographic variability in diagnosis and treatment suggesting both inequality and inequity. The other was a student of all things Deming, a land where there were no bad employees, just bad processes. Both believed that the answer to healing an obviously unwell US health care system was data, analysis and systematic reform.

Jack Wennberg, a graduate of McGill who did his residency and public health training in epidemiology at Hopkins before heading north for a professional lifetime at Dartmouth, received a boost from President Lyndon Johnson in 1967 as Johnson was struggling to understand and control explosive hospital costs in the wake of his landmark Medicare legislation. Working off of a $350,000 NIH grant, Wennberg would later recall that “Our results were fascinating, because they ran completely counter to what conventional wisdom said they would be….It was immediately apparent that suppliers were more important in driving demand than had been previously realized.”

Don Berwick was a product of Boston. He graduated from Harvard College and Harvard Medical School before doing a residency at Boston Children’s and gaining a degree in Public Policy at the John F. Kennedy School of Government. One of the first proponents of quality measurement, he took a post as Vice President of Quality-of-Care Measurement at the Harvard Community Health Plan in 1983. Over the years, Berwick was fond of sharing the quote, “Every system is perfectly designed to get the results it gets.”

When the IOM landmark publication, “To Err Is Human: Building a Safer Health Care System” came out in 1999, Berwick was one of the lead contributors. The report stated, “The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system.” But the statement that caused an uproar at the time, and an avalanche of hospital process reengineering and measurement, was the substantiated claim that some 98,000 American lives were needlessly lost each year as a result of human mistakes in hospitals.

Nearly two decades later, one would think all the data mining, process reengineering, and sincere hospital-centric collaborative efforting would wrestle the caring defects to the ground. And yet, a well respected study in the Journal of Patient Safety in 2013 placed the number of annual deaths at between 210,000 and 400,000. The offered cure? The author at the time seemed to suggest more of the same, stating “The epidemic of patient harm in hospitals must be taken more seriously if it is to be curtailed. Fully engaging patients and their advocates during hospital care, systematically seeking the patients’ voice in identifying harms, transparent accountability for harm, and intentional correction of root causes of harm will be necessary to accomplish this goal.”

What’s the problem here? The problem is that all the reengineering in the world will never correct the American health care system unless we address the “original sin.”

In 1947, in the wake of WWII with casualties flooding the homeland and explosive chronic disease an endemic reality, Canada and the U.S. grappled with the appropriate response. Canada, first in the province of Saskatchewan, and a decade later for the entire country, chose a course whose step one was universal health coverage for all Canadian citizens. They boldly declared that Canada and its economy and culture could never be healthy and productive unless her citizens were healthy. In Canada, access to basic affordable care was declared the right of all citizens and was supported by public funding. The government became the payer, but the caring was the responsibility of the 13 provinces and territories.

Out of that decision, that Step 1, came three other derivative steps. Step 2. The government determined what basic services would be covered by all plans. Step 3. Each province or territory created a budget within their resources which effectively created priorities for funding with a heavy focus on prevention and social determinants of health over reflexive intervention and use of technologic wizardry to wage “war” on disease. Step 4. Over the years, annual budgeting has forced a reconsideration and at times a reordering of priorities, ensuring a collaborative, transparent, and thoughtful process of continuous improvement focused on improving the quality of caring while efficiently dispatching limited resources.

In America, in 1947, we chose a very different course. We rejected universality and declared health care a privilege not a right. That was our “original sin”. In its place we embraced profit-seeking free enterprise, complexity, inequality, reckless competition, and an unerring faith that American ingenuity, innovation, and scientific discovery would eventually win out. Disease would be conquered and we – at least some of us – would be healthy.

Over the decades that followed, we’ve had many opportunities to see the light, After all, when Jack Wennberg received that $350,000 grant from President Johnson, it was clear that we were off course. And over the years, our best thought leaders, almost exclusively from premier academic health systems, have sought out evidence, mined the data, and reformed the processes from the tip of the American health care iceberg. They’ve failed. And they will continue to fail unless together we accept and correct our “original sin.”

It is time now to make equal universal access to basic preventive oriented health care the law of the land. The steps this will trigger will be reparative. Without it, we will continue to decline.

Comments

2 Responses to “American Health Care’s “Original Sin””

Charles Fahey
May 17th, 2017 @ 2:37 pm

Mike, Thank you for this and a number of insightful pieces. I find your work to be both timely and helpful.

Peace and all good things,

Chuck
Mike Magee
May 17th, 2017 @ 3:40 pm

Thanks, Chuck! That means a great deal to me, especially coming from you! Blessings, Mike