The mirrored-windowed facade of Blue Ocean Medical Center (or Blue Ocean Med) only just catches the watery October sun as it sinks below the city skyline. Situated between the edge of a mid-size city and the Atlantic Ocean, Blue Ocean Med is a hub for regional healthcare. Like most hospitals it is also among the biggest employers of the region.
In the particular case of Blue Ocean Med, they are only outmatched by the local tinning plant. As an organization, however Blue Ocean Med has no match for complexity. The hospital aims to serve the regional community on all relevant aspects of specialist care. They offer all regular diagnostics and surgical interventions, but also prevention programs, radiotherapy, e-health and research and development. For anyone familiar with hospitals: a truly wonderful organization and a wholly unremarkable general hospital. It is actually almost identical in organization, size and offering to both of the two nearest general hospitals.
These also deliver (in about equal measure):
Extensive high-tech facilities
A comprehensive care offering
Fee-for-service
E-health
Qualified and caring personnel
R&D and cutting edge medicine
Blue Ocean Med, like all general hospitals, is struggling with issues of quality, cost and profile. Focused clinics are taking more of their market, insurers are tearing down tariffs, real-estate cost is through the roof and the media are just waiting for anyone to slip up. In order to stand up to all this while delivering ready access to high quality yet affordable care, they know they must make some fundamental changes. They need to move from marginal improvement to far better ways of doing things. But how? What can they do differently with real impact? Can they afford to? And how can they do this without doing the exact same things everybody else is doing?
Follow Blue Ocean Medical in a series of blogs as it tries on alternatives on the above characteristics. Each article will feature one characteristic, yielding one alternative Blue Ocean Medical. There are three reasons for following these thought experiments. First; the dramatic changes Blue Ocean Med goes through may inspire those of you in healthcare to start doing things a little differently too. Second; I hope you will challenge and build on the presented ideas, working toward a greater truth and having fun while at it. Third I hope that some of you may one day join me in actually building Blue Ocean Med.
BOM Five: Evidence based only please
‘We really don’t know’ and ‘There is no way we can know for sure, but…’ are two messages we dread and hardly ever hear in the doctor’s office. These are rare moments of clarity and honesty. Because in many cases doctors simply don’t know if or why certain treatments will be effective. A 2012 study showed that of a whopping 50% of healthcare services offered, the impact on health is either negligible or unknown. It is difficult to say which whopping half, because the actual list of ineffective interventions has only recently been drafted and the first 1300 were published this month. And with or without a complete list we are all very dependent on specialists in determining healthcare, often by choice. In healthcare supply has always been a better predictor of consumption than demand.
Now take into account the fact that this supply shows enormous variance between specialists, institutions and regions. In some cases it seems like everybody is doing something different when faced with the same question or complaint. Even within the same hospital. And about half of what’s been done has little to no positive impact on health?! Research also shows that the greater the regional variance in activities, the weaker the evidence base for effectiveness.
So Blue Ocean Medical Center’s CEO summed up the sorry state of affairs sketched in these reports in his own words: ‘I am running an integrated healthcare company in a market where;
supply is a better predictor of consumption than demand,
practices show great variance and little effectiveness,
we are reimbursed for quantity of services, not effectiveness
half of those reimbursed services are ineffective and may well be detrimental to our clients
not even counting missed diagnoses, re-admissions, failure, complications or negative side-effects…”
As much as he believes in his hospital, loves his organization and trusts his staff, the CEO felt an uneasy guilt crawling up his spine. What would happen, he wondered, if he would put his foot down and forced the issue? What if Blue Ocean was to only provide services, treatments and medication that have a clear evidence based positive impact on the health of its’s patients? Would they be cheered as a beacon of sense in a field gone coco? Would they take the market by storm? Nope. They would be out of business. For three clear reasons there would be a massive pushback:
Delusion of manipulability
The first push-back would come from patients and their families. They don’t want to hear that the best way to go is doing nothing! In this day and age we live under the misguided notion that all health is manageable, life is makeable and death is to be fought off. Read the obituaries: ‘He fought this terrible disease bravely until the end’, is a common enough line. And in that fighting spirit we are overconfident in what medication, doctors or lifestyle management can do. Hell, we think that data analytics, digital watches and goji berries prevent cancer. Patients, the CEO fears, want the comfort of the idea that –however ill they are- something can be done and is being done. Patients want hope more than they want truth.
Propensity to fight
This fighting spirit is actually stimulated by the medical profession. Professionals are trained to observe, listen, investigate and act to improve health. To be cool and collected under pressure and never jeopardize a patients’ health. The latter being difficult when there is no evidence base. ‘It doesn’t hurt to try’ is a common enough outcome when considering courses of action. That’s an admirable trait and we love our doctors for it. But oftentimes it does hurt to try. Treatments and medications may very well be detrimental to quality of life.
Or have long-term side-effects which are more damaging than the actual disease or complaint. We need to stick to what we know will work. We need to know what the net-impact is of services, drugs and interventions before unleashing them on ourselves. As Sun-Tsu wrote: only fight those battles in which victory is certain.
Losing money and patients
When Blue Ocean cancelled all reimbursement of ineffective services and medication, they started to lose money fast. Doing nothing may be the best option for some patients, it certainly is not for the P&L. And as long as reimbursement is based on fee-for-service and Blue Ocean stands alone in this practice, they will lose both money and patients. People will go to providers who will do something, anything to help them (or their child) fight disease.
Whether this choice is detrimental to health or not. A warning to all who claim that direction of healthcare delivery is to be put squarely into the hands of patients. Yes, we want treatments to have evidence based positive impact. But all parties involved need to come together on this subject to make this work: professionals, patients, management, government and healthcare insurers.
The R&D to deliver the evidence base is the subject of next edition of Blue Ocean Medical Center. To be continued…