Heard a mind-blowing presentation by Robert Mechlenburg, MD, Chief of Medicine at Virginia Mason Medical Center in Seattle. This is a medical center that has bought hook, line and sinker the Toyota “lean production” model to improve quality and lower costs. The Toyota LP model has two key parts: 1. Build in Speed (just what is needed, when it’s needed, and where it’s needed); and 2. Build in Quality (mistake proofing, stopping the line, evidence-based medicine). When combined the right way, both component lead to less waste and lower costs, as well as care that is better, faster and more affordable.
The marquee example of what they did involved back pain treatment.
Here’s the traditional patient care path:
Wait to See Primary Care Physicians (PCP)
See PCP
Wait to see PCP again
See PCP
Wait to get MRI
Get MRI
Wait to see PCP
See PCP
Wait to see Specialist
See Specialist
Wait for referral to Physiatry
See Physiatrist
Wait for referral to Physical Therapy
See Physical Therapist
Here’s the new model based on applying the LP system:
Direct Referral to Physical Therapist
See Physical Therapist.
Here’s the Value Difference:
Cost to VMMC: 2005 – $2272; 2006 – $878
Paid by Employer or Insurer: 2005 – $2353; 2006 – $845.
Staff Needed: 2005 – 18.6; 2006 – 8.9.
Employee Work Days Lost: 2005 – 20; 2006 – 3.
Patient Satisfaction Score in 2006 (5.0 highest possible rating): 4.8.
Problem – in the old system, VMMC made money, and in the new system, they lost on every encounter. Answer, partners such as Starbucks increased reimbursement for physical therapy so that VMMC makes money in the new arrangement.
By my calculation, more than 60% of the payment under the old plan was sheer waste and inefficiency. How much more waste and inefficiency is there in medical care? VMMC says “a lot.” VMMC is applying this process improvement model everywhere in their system with some amazing results.
Do fantastic stories like this happen in Massachusetts? I’m asking seriously. I know Boston Medical Center had some great success a few years ago reducing ER overcrowding by improving patient flow. But these stories seem to me few and far between here in Massachusetts. Maybe they’re all over the place and our provider systems are just, well, shy…?
Hey folks, how about it? Aren’t we supposed to be better than Seattle and anywhere else? Let’s hear about it.
John McDonough
By my calculation, more than 60% of the payment under the old plan was sheer waste and inefficiency. How much more waste and inefficiency is there in medical care? VMMC says “a lot.”
The “old” plan is EXACTLY what ‘managed care’ or ‘coordinated care’ does – you know, the stuff that you approve of so highly as a means to reducing medical costs by having a patient’s care ‘coordinated’ by the primary physician (PP).
This insistence that a patient MUST be referred to a specialist by the GP/PP is objectionable for two reasons:
(1) The GP/PP picks the specialist without any consultation with the patient and typically picks the name of someone who is within his ‘approved’ circle or whom he uses so routinely that he no longer thinks about whether this orthopedist is the best choice for this type of case or whether he should find someone else. The patient has utterly no control over whom he is sent to – and is stuck with the one selected by the GP/PP even if inept, unskilled with that particular problem or personally unacceptable to the patient because of personality. (And it is extremely aggravating to have to have the GP/PP’s office call the specialist and make the appointment without consulting the patient who is then just told they are to be there at a day and time without regard to their schedule and obligations.)
Not all specialists specialize in all areas of their field. For example, some orthopedists do shoulders, some do knees, some hips – and some call themselves general orthopedics and do not have anything close to the depth or knowledge and experience of an orthopedist who works in primarily one area.
I’ve personally been through that nonsense of ‘refer to the local guy because he is handy’. When an MRI showed tendonopathy of the major neck-shoulder tendon (a test ordered by my GP when I told him to run an MRI after the Xray didn’t show anything and he ask what I wanted to do ), I got stuck with 2 “generalists” before I announced ‘to hell with these nitwits, I’m going home to the Cleveland Clinic.” The first local orthopedic surgeon did admit that he didn’t have a clue as how to deal with the injury and actually said “you need a specialist” (and I’m wondering ‘and what are you supposed to be, eh?’) He sent me to another in the state who was the head of the ortho dept. at the university medical school. That one was a complete moron. He claimed that the bursae from the shoulder joint had migrated to the middle of the back near the scapula and that was the cause of the pain – and I informed him that he was an incompetent fool, I had been reading ortho xrays on my animals for 30 years and his diagnosis was impossible, and to stick his bill. I then called the Cleveland Clinic and made my own appointment there with no need for the referral nonsense. The Cleveland Clinic orthopedist specializing in shoulders immediately diagnosed massive tearing of muscles and tendons with extensive scar tissue destroying the internal rotation, and that the damage was inoperable and irreparable. (When I told him the 2nd orthopedist’s ‘diagnosis’, he laughed and said he must have missed that day in med school because he had never heard of such a thing.)
Now THAT is patient-directed care. If I had not been knowledgeable and persistent, I would never have gotten the appropriate care and been merely handed morphine derivatives for debilitating, incapacitating pain with a diagnosis of ‘scapular bursitis!’
(2) I now have every 4 month invasive chronic pain management procedures performed. The procedure is highly unusual and until 2 months ago, no pain specialist in my state had even performed it and 99% of GPs have never even heard of it. It is, of course, done at Cleveland. This will never end. I will need this done regularly until I die.
If I had to deal with an insurer with their ‘you must stay in network unless impossible conditions are met” and “must have a GP/PP referral to specialist”, here is what I would go through EVERY 4 months to establish I needed the procedure, I had not improved and it was not available in this state:
Call GP for appt.
See GP – tell him give a referral to “network pain specialist”
Call GP to find out appointment date
Call network specialist to change appointment date
See Network specialist – one in my state who is not qualified to do procedure & get referral to Cleveland
Call insurer and have fight about going ‘out of network” to another state
“ “ “ “ “ “ “ “
Call network specialist and tell them referral okayed and to schedule the referral
Call network specialist and find out appointment date
Call Cleveland to change appointment
See Cleveland specialist for procedure
Physician office visits 2
Calls 8 (minimum)
Pain procedure 1
Here is what I do:
Call Cleveland for appt.
See Cleveland specialist for procedure
Physician office visit 0
Calls 1
Pain procedure 1
I’m happy (a 5+++), the treating specialist is happy, my GP is thrilled he doesn’t have to even fill out forms about, let alone pretend to deal with and ‘manage’, a condition that requires one of the top 5 medical facilities in the US to diagnose and manage and the insurer is very hapy with the far far lower bills. You figure out the cost and time savings for everyone involved.
By the way, I’m not impressed if you hypothetical patient was simply sent for PT because they had lower back pain. Presumably someone at sometime did definitively diagnose the cause of the pain. Sending a patient straight to PT just because they have lower back pain rather begs the question of the cause of the pain. PT is not the treatment of choice for a herniated or degenerating disc or cracked vertebra and can worsen the problem if PT proceeds as if it were muscle spasms or a strain. What ?- in the 2nd scenario the nurse-practitioner who saw the patient and sent them to PT didn’t even do an xray? In any event, who sends a patient to a psychiatrist for what must have been muscle pain after the “Specialist” presumably ruled out a structural cause. This example makes no sense whatsoever! The GP could read an Xray and get the MRI results. It was either structural or muscular. If structural, get thee to an orthopedist or neurosurgeon and if muscular, off to PT. What is a psychiatrist doing in there?