Future Now
The IFTF Blog
Interview Summary - Dr. Richard Bohmer, Harvard Business School, April 1, 2009
HC2020 Interview Summary: Richard Bohmer, Harvard Business School
Interviewer: Richard Date: March 29, 2009
1. His/her work
Trained as an MD, but has not practiced for 15 years.
At Harvard Business School, he has focused on the management
& delivery of health care from a perspective of process.
His big project: a study of the adoption of minimally
invasive cardiac surgery through a lens of "systematic
learning" - who learns these new techniques fastest, and
why.
Also looked at what predicts success in the organization
of neo-natal ICUs; how hospitals organize clinical care,
including the "hospital within a hospital" model.
Has a new book coming out in June: Designing Health Care:
Using Operations Management to Improve Performance and Delivery
(Harvard Business School Press) tinyurl.com/d6qsxw
TRENDS/CHALLENGES
2. How optimistic about future of health/healthcare in 2020?
Depends on what we mean by health care. "We have a huge amount
of work ahead of us."
We need to think much more systematically about the determinants
of health: housing, early childhood education, social welfare
policies. Other countries are much better at integrating these
sectors with health care policy.
Example: You can't talk about the problem of obesity without
talking about how we educate 4-year olds, the availability of
high fructose corn syrup drinks in schools, etc. Obesity is
NOT just a problem for health care.
Progress will be slow; it will require a change in the mental
model of how we think about health.
Progress we also be slow because the changes need to
be broad and systematic.
3-4. Biggest trends or challenges & responses
1) Health care is in the middle of a big transition from a
focus on the individual practitioner -- their training, their
use of technology, how they interact with patients, etc --
to a focus of how we DEPLOY TEAMS -- how they are organized
and deployed, how we measure their effectiveness, etc. We
need to shift from a focus on the "exquisitely trained
professional practitioner to the organization of teams of
multiple professionals and how they are managed, compensated,
supported, etc.
It's like airlines: a well-run airline is NOT just a matter of
having great pilots, but having effective systems to support
pilots, keep planes well maintained, schedule effectively, etc.
Health care example: if a patient with artery disease needs a
stent, the system has got to deliver the patient promptly to
the cardiologist. Time is critical. Key is having the right
organization of the SYSTEM to deliver quality care.
This is a matter of properly designing each individual unit.
Forces supporting this trend:
- greater interest among payers (employers, govt, individuals)
in OUTCOMES. People are beginning to think more about the
VALUE of the health care they are paying for.
- move toward linking payments to outcomes, bundling payments
- younger people expect quality service: "Americans expect
service excellence" -- which increasingly includes health care.
Some providers (Intermountain Health, Cincinnati Children's)
are beginning to design care around producing better outcomes.
How doctors are organized is becoming more important than
characteristics of individual practitioners. The key is
HOW RESOURCES ARE CONFIGURED.
2) Second big trend is the greater involvement of patients
in their own health & health care. Rise of retail clinics
is an example; they are now as popular among blue-collar
workers as white-collar workers (something of a surprise).
Another example are the health-oriented social networks,
though the currently involve only a very small percentage
of the population -- could become "a big deal"
This trend changes what we mean by "health care teams" --
patient could be an important part of the team, though this
is NOT how health care is organized today: "You can still
make an audience of professional providers angry by talking
about patients as 'customers.'"
We now have a complicated blend of "uncertain care" and
"certain care."
6. Challenges/responses not on radar now?
- A majority of health care delivery systems today don't
realy understand what reimbursement for outcomes will
mean -- will require a fundamental shift.
- Payers are increasingly restless, willng to try
new approaches
EXAMPLE: Bridges to Excellence ("Non-profit organization
developed by employers, physicians, health care services,
researchers, and other industry experts with a mission
to create significant leaps in the quality of care by
recognizing and rewarding health care providers who
demonstrate that they have implemented comprehensive
solutions in the management of patients and deliver
safe, timely, effective, efficient, equitable and
patient-centered care." bridgestoexcellence.org)
FUTURE SCENARIOS
7. Most preferable scenario
- We will have made "a little progress" toward the
goal of reorganizing health care. In the most
successful examples, doctors will be managed, their
freedom will be constrained by protocols. This won't
happen quickly or quietly.
- New doctors in training will learn to expect more
oversight and coordination -- but the training of
doctors has not yet changed in this way - should be
somewhat different by 2020.
Example of a "shining light" - a group of 8 primary
care practitioners along with nurse practitioners will
all agree on how to address health problems. Some NPs
may be specialized (e.g., diabetes care); group may also
include health educators who focus on supporting a subset
of the practice's sickest patients.
Practitioners will be more pro-active in agreeing on how
common problems will be treated; these agreements will be
reflected in how the practice is organized and managed. Care
needs to be "deliberate" not "reactive."
Another model for excellence: all parties involved in dealing
with, e.g., Congestive Heart Failure (CHF) -- including docs,
hospitals, nurses, community health groups, even schools --
gets together to figure out how to implement a comprehensive
approach to care, change how funds for care are allocated.
You can find examples of this approach in places like the
UK, New Zealand, as part of a National Health
Service, but not currently in the U.S.
[The Medical Home model is a partial step in this direction,
but it is still "doctor-centric," still focused on doctors
waiting for patients to come through the door rather than
engaging with them in their everyday lives.]
8. Most plausible scenario
We will "edge slowly" toward the most preferable scenario,
but we won't really make much progress. There is very little
fundamental restructuring. Health of Americans may get worse
before it gets better.
9. Most negative scenario
We just keep doing what we have been doing. By 2020, the oldest
Baby Boomers (will be 74), will start to get really sick, need
more medical care, but the system will still be highly fragmented
and inefficient
10. Wrap-up
A key to change is distinguishing between the FINANCING of health
care and PAYMENT for health care services. There can be different
approaches to improving both. Today, the focus is mostly on
the former, but we need to look harder at the latter.
Much needed change in health care delivery is a mundane
matter of blocking and tackling - not glamorous but not
simple either.
We need to look again at capitation as a strategy -- in a
capitated world, "the most benefits accrue to the best
organized providers." We need capitation to stop being
a dirty word.