Atul Gawande understanding the forces driving healthcare change

A growing body of research has identified both the opportunities and the obstacles of moving away from fee-for-service healthcare delivery to approaches that result in higher-quality care and improved outcomes.

Atul Gawande, MD, MPH, a surgeon at Brigham and Women's Hospital, Boston, professor at Harvard School of Public Health and Harvard Medical School, and director at Ariadne Labs, has authored some of the key research in the movement toward a system that pays based on the quality of care provided. In a conversation with hfm, Gawande shares his views on key ways to deliver higher-quality care at lower cost as well as the increased focus on transparency of cost and quality information.

Q. How did you, as a surgeon, come to focus so much of your life's work on the finance of health care?

A. I came to this subject from a physician's point of view, with an interest in understanding how we become good at what we do as healthcare providers. As a resident, I began writing about the puzzles of how to become better as a physician, about the learning curve, and about the experience of care. In my efforts to grow as a physician, I became very aware of how fundamentally important the healthcare delivery system is in determining a physician's effectiveness. That was not in my textbooks and not what 1 was taught in medical school; it was the silent curriculum. In the hospital setting, I learned that making the system work and being able to connect the dots for patients was as important as my surgical technical skills: Will the radiology exam be completed on time? Will anyone track down the result and make sure it gets to the patient? After a patient leaves the hospital, will that patient get the prescribed antibiotic and proceed to take it correctly? As I started writing about my experiences, I began to see lots of evidence that organizations that have higher volume do better than others.

It was an unexpected thing for me to become a writer midway through my surgical training. I had not written anything before becoming a surgical resident. One of my earliest articles in The New Yorker was about when physicians make mistakes; it dealt with how we handle errors and the opportunities for reducing errors. That led to a circuitous pathway that has involved both writing, where I have been able to probe the edges of where we're going as a healthcare system, and policy, where 1 have been able to speak to the experience of what it means to be a patient or a clinician.

I used to work in politics. Before medical school, 1 worked on Capitol Hill for a congressman. Midway through medical school, I took a leave of absence and worked first for the Clinton campaign and then in the White House as part of the failed healthcare reform effort in 1992 and 1993. When I returned to medical school and began my surgical training, I used my writing and, later, my research to probe the same issues for which I had been interested in connecting the dots: what it's like to be a patient, what it's like to be a physician, and the larger forces in the system that deeply affect what happens at the front line.

That's where my interest in the finance of health care evolved. I would use my writing to probe how different people experience care throughout the system, and I would use my research to test new ideas and examine the evidence that resulted from those efforts. Over time, that approach has enabled me to gain a big-picture view of the experience of care in all of its complexity.

Q. As the keynote speaker at ANI: The HFMA National Institute this June, what healthcare policy developments will be your focus?

A. I think we have come to a place in care where we as practitioners are overwhelmed by complexity. Because of complexity, we have divided up the tasks of how we deliver care and service, and that means that we are suddenly teams of people instead of individual practitioners. That has completely changed the relationship between healthcare organizations and care providers.

And it has caused finance managers to emerge as crucial partners in the actual deliveiy of care. We cannot achieve great care at an affordable cost without a new partnership between finance leaders and clini - cians in designing care and in changing incentives that yield less-than-ideal systems and care.

Q. Are improvements also dependent on getting patients more involved in their care?

A. It depends. If you think of medicine as one industry, then that's completely wrong. We provide thousands of different services. And when you think about the different parts of care, patients at different times have more or less power over their care. In an operating room, for example, a patient who is asleep on the table has an extremely limited ability to affect outcomes. It's like being a passenger on a plane, where you really hope the pilots up front know what they are doing. On the other hand, the set of projects around end-of-life care and improving our systems for better end-of-life decision making present an altogether different situation. The most powerful tool in an end-of-life care tool kit is simply the conversation between the physician and the patient about the patient's prognosis; about the trade-offs the patient is willing to make and not willing to make; about the patient's goals and fears. That is 350-50 shared decision and shared conversation that will determine how favorable the outcome is going to be for the patient. And it has huge implications not only for what care is provided, but also for how much that patient will suffer and how costly the patient's care will be.

At Ariadne Labs, we are finding that the choice of approach to end-of-life care can make a huge difference. We're testing an approach at the Dana Färber Cancer Institute where we finance training for the physicians on how to conduct end-of-life conversations. We provide data to let physicians know which of their patients have the highest risk of dying in the next six months, and we alert them to important issues that should be addressed, with questions such as, "What are the trade-offs he is willing to make and not willing to make in his treatment?" We're testing whether this training and the conversations that result produce a significant difference in various outcomes of care, including patients' levels of suffering, anxiety, and frequency of unwanted care.

Q. Are there any negative outcomes on the front lines you see from the various tweaks the Obama administration has announced in recent months to the implementation of the Affordable Care Act (ACA)?

A. When Medicare passed, improvements were required within one year, and they have been required every year since. That's going to be the case with the ACA. We're learning about what works and doesn't work with bundled payments and accountable care organizations, and those provisions will need to evolve. And there is a huge amount of learning regarding enrollment of patients in the insurance marketplaces and what kind of experience consumers have in trying to obtain coverage.

One of the biggest forces affecting consumerism in health care right now is the move toward limited networks and very high deductibles for patients. That's producing a tremendous combination of anxiety for consumers and at least some degree of shopping around that hasn't been seen before. Over the past three years, the healthcare landscape has changed rapidly, with increased demand for hospitals and physicians to be more transparent about our costs and to be able to help patients understand what they will have to pay if they come to us for a procedure or diagnosis versus going elsewhere. The information flows are not where they should be right now for patient decision making. We haven't combined information about quality with their cost picture. But the experiences some people are having as they suddenly discover that they have thousands of dollars in unexpected payments to make when their physicians and hospitals haven't alerted them to the out-of-pocket cost of their care-and when physicians and hospitals actually have no idea what type of costs they are imposing on patients-have caused tremendous anger and fear. This sort of sticker shock has been happening widely as employers shift rapidly to high-deductible, limited-network plans.

Q. Are any providers or insurers doing a particularly good job in being transparent with the information patients want in this emerging environment?

A. Most of the big insurers post information on their websites that allows patients to learn what a procedure typically costs at various facilities, and they are providing services for people to receive this information over the phone, too, because patients have a hard time getting that type of information from hospitals and physicians. We're moving very rapidly to a point where nearly every insurer will offer this information. It's not clear to me how many people actually use such services and how much their behavior changes based on the information they receive.

And then there are other decisions like, "Should I get an MRI or an ultrasound, or should I skip the imaging test altogether?" At a certain point, the patients I've seen throw their hands up and say, "I have to trust someone." And they do not typically trust insurers to help them make this decision. They trust the physician.

But then there is tremendous anxiety, because while the physicians are saying, "This is what you need," the physician doesn't necessarily have information regarding what the patient's costs will be to help the patient understand the financial impact of that decision. If this information were readily available, physicians could have conversations with patients along the lines of, "Oh I didn't know that test would cost $5,000. Here's an equally good approach that is $500." It takes a combination of clinical and financial information for a patient to make a good joint decision with the physician.

And that goes back to the issue of shared decision making. Right now, the information needed for good decision making is not there. There is information that the insurers and others have, but patients and physicians typically do not have access to this information at the point of decision making. So there is tremendous potential for conflict. In many ways, the force behind the increase in high deductibles and limited-network plans is representative of an even bigger experiment than what is going on with Obamacare. It's an experiment in driving consumer behavior, and no one has any idea, really, about how much good care results from it and how much bad care results from it.

Given that patients are having to pay hundreds of thousands of dollars for care under many health plans and can't afford some of the choices that physicians are presenting to them, it's hard to know what impact transparency on quality-of-care information might have on consumer decision making. There's very little data right now. What we do know is that with the number of people who face large out-of-pocket expenses, as providers, we're being asked to tell people what we don't know-about cost and about quality. And that's a problem.

"It takes a combination of clinical and financial information for a patient to ^ make a good joint decision 9 with the physfojan."

About Atul Gawande

Atul Gawande, MD, MPH, is a surgeon, professor, writer, and public health researcher. He practices general and endocrine surgery at Brigham and Women's Hospital and is professor in the Department of Health Policy and Management, Harvard School of Public Health, and professor in the Department of Surgery, Harvard Medical School. He is executive director of Ariadne Labs, a joint center for health systems innovation. Gawande also is founder and chairman of the Lifebox Foundation, which spearheads surgery safety innovations.

Gawande has served as a staff writer for The New Yorker magazine since 1998. He has written three books: Complications, Better, and The Checklist Manifesto.

He was a legislative assistant for Rep. Jim Cooper (D-Tenn.), who was author of a "managed competition" healthcare proposal for the Conservative Democratic Forum. He took a leave from medical school to become an adviser to President Bill Clinton's 1992 campaign and was a senior adviser for health policy in the U.S. Department of Health and Human Services after Clinton's inauguration. He worked on the <org>Clinton Health Care Task Force.

He obtained an undergraduate degree from Stanford University in 1987, was a Rhodes scholar (earning degrees in philosophy, politics, and economics from Balliol College, Oxford, in 1989), and graduated from Harvard Medical School in 1995. He also earned a master of public health degree from the Harvard School of Public Health in 1999.

Rich Daly is a senior writer/editor in HFM A's Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare.