A Grand Challenge Crying Out for Leadership

The November 25 Sunday New York Times included yet another editorial bemoaning "The High Cost of Health Care."  It is a good editorial, and I generally agree with both its list of Causes as well as its recommended Solutions.  But I wonder if anything will come of it.

The editorial points out that "health care costs are far higher in the United States than in any other advanced nation, whether measured in total dollars spent, as a percentage of the economy, or on a per capita basis."  This would be fine, or at least tolerable, if the U.S. enjoyed a quality of health care commensurate with its higher costs.  But as we well know, this is not the case. 

The Commonwealth Fund, a private foundation, reported in a recent article, "Despite health expenditures that are twice those of the median industrialized country, a new national scorecard of U.S. health care system performance finds the nation falls short on key indicators of health outcomes, quality, access, efficiency, and equity."  It goes on to say that "Among 19 industrialized countries, the U.S. ranked 15th on mortality from conditions amenable to health care, or deaths before age 75 that are potentially preventable with timely, effective care. The U.S. rate was more than 30 percent worse than the benchmark—the top three countries. The U.S. also ranks at the bottom for healthy life expectancy and last on infant mortality."

There is nothing new here.  We have all been reading editorials and reports like these for a while now.  Calls for action abound.  Among the top recommendations of the 2004 U.S. National Innovation Initiative was a call to build a health care test bed, including electronic health reporting, standards for an integrated health data system, pilot programs for international exchanges on health care research and delivery, and the use of performance-based purchasing agreements.

Finally, the 2005 report, A Healthy System issued by the Technology CEO Council, concluded, "If there's one thing that everyone agrees on about the U.S. health care system, it's that it isn't, in fact, a system," and that "the sad truth is that in health care today the whole is much less than the sum of its parts."  The report went on to say, "We will never fix this problem simply by tinkering with its parts. As a practical matter, and as a moral imperative, we have to address the systemic problems of health care.  And the most glaring - and promising - is health care's shocking lack of modern, networked information technology (IT), and the lost quality and efficiency that result."

What is going on?  How can a problem be such a national priority and yet be so frustrating, with progress that is both woefully insufficient and very slow.  I have been thinking a lot about this in the last year, especially in my work with colleagues at MIT, as we are trying to define how best to apply to health care the kinds of systems, technologies and engineering practices that have been so successfully applied in a variety of other industries.  Let me offer some personal thoughts.

First of all, health care systems are incredibly complicated, perhaps the most complex engineered systems in our midst, rivaling natural systems like those in biology in their intrinsic complexity.  Health care is a true Grand Challenge problem - in my opinion, the grandest such challenge for anyone studying and developing complex engineered systems. 

Generally, when faced with a problem that is demonstrably hard to solve, and whose solution will have a significant economic and social impact, the federal government gets involved, usually by funding the proper research in universities, involving its national laboratories, and forming partnerships with industry.  That has certainly been the case with high performance supercomputing and with advanced networking technologies and platforms, including the Internet.  The National Science Foundation (NSF), the Department of Energy (DoE), the Department of Defense (DoD), and other federal agencies have a distinguished track record of supporting grand challenge technologies and applications.  Similarly, the National Institute of Health (NIH), the nation's top medical research agency, supports the most advanced research leading to medical discoveries that improve health and save lives.

But who supports research in health care systems - how to deliver it, how to improve its efficiency and quality, how to lower its costs  and how to reduce its unacceptable error rates?  I have asked many people that question, and the answer is not at the tip of anyone’s tongue, as it is for advanced supercomputing or medical research.

The U.S. Department of Health and Human Services (HHS) seems to have the lead here, through its Agency for Healthcare Research and Quality (AHRQ), whose stated mission is "to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.”  In addition, HHS supports a relatively new Health Information Technology initiative, whose primary mission is to help achieve access to an interoperable electronic medical record for most Americans by 2014, as well as to use such electronic records and other health information technology to help control costs and reduce dangerous medical errors.

This sounds promising, but there is a lot to do.  I frankly had not heard of AHRQ until I started doing research for this blog entry, perhaps because it is all so new.  I think that it is also telling that when you hear complains about the state of the U.S. health care system, as in the editorial and articles above, you rarely hear calls for HHS, let alone AHQR, to take action.  They are just nowhere near as well known as NIH, NSF, DoD and DoE as supporters of research, especially the grand challenge style of research needed to make progress in such an incredibly complex area.

Then there is prestige.  Health care reminds me of manufacturing thirty years ago.  As we know, U.S. industry, especially the auto industry, did not pay serious attention to manufacturing, including key issues like productivity, quality, costs and tapping into the expertise of the plant floor workers.  Neither did our top engineering schools, or the government agencies that funded their research.  Manufacturing was just not considered a glamorous field of study or a career to be pursued by graduates of engineering and management schools, unless you had no other choice.

This past June I heard a fascinating talk by Fujio Cho, chairman of Toyota, at the IBM Business Leadership Forum.  Cho-san explained to us, in clear and simple language, the commonsense innovations underlying Toyota's revolutionary production system, which has become known as The Toyota Way. The system is essentially based on the constant education of both employees and parts suppliers, so they can improve in the performance of their functions; working on innovation as a team, so that people in related functions come together and share ideas; and the concept of kaizen or continuous improvement.   

Above all, Cho-san told us, Toyota focused its efforts on the principle of clearly separating work from waste.  They analyzed each step in the work process, identified what was absolutely necessary to get the work done, and everything else was classified as waste.  By eliminating such waste on the production floor, Toyota saw tremendous simplification in the work processes. Productivity, as well as quality, started to rise dramatically.

Today, medical research is viewed as a very glamorous field, the recipient of billions and billions of dollars in funding from NIH and other sources.  Everyone knows that eventually, the fruits of all that research have to get to the people that will hopefully be helped by them through the health care system.  But that aspect of the problem has not received much organized attention until recently, a state of affairs that has led us to our current near-out-of-control situation.

Perversely, the more numerous and sophisticated our advances in medical research are, the more of a strain they cause on the health care system, whose job is to deliver these advances to patients.  As we know, the system is already way overtaxed and lacks the resources, especially the research and education, to do its job properly, let alone absorb even more medical advances coming its way.  No wonder we find ourselves in our current situation.   

What this grand challenge problem is crying for, more than anything else, is leadership.  We have more technology than ever at our disposal, which if properly organized should enable us to start making progress in improving the productivity and quality of health care - from the Internet, to sensors, to mobile devices and real-time information analysis.   

Someone - the next U.S. President, regardless of who he or she is, it is to be hoped - will stand up and, like John Kennedy in May of 1961, declare that our nation should commit itself to improve significantly the productivity and quality of health care for all over the next decade.  And, like JFK in that memorable speech to Congress, the new President needs to tell the country that no single project in this period will be more important to the nation, or more difficult or expensive to accomplish.  Let's hope we do so before the situation deteriorates even further.

Comments

[James Drogan]

You've long been one of my favorite reads and this post is of the type that keeps me coming back -- thoughtful, comprehensive, easy-to-understand, dealing with a significant issue.

I think it highly unlikely that the leadership you call for will be found at the national level. What then is required is leadership in various niches of the socio-political-economic structure -- companies, states and counties, universities.

This, it seems to me, will require uncommon commitment on the part of rare individuals who command in these niches. This approach invites fragmentation of effort, but perhaps some sort of unifying collaboration can help overcome this issue.

I agree with you that the health system is complex, but I also believe it can be simplified.

What is broken is that most critical part of any system -- the human. Political correctness, obfuscation, special interests, fear of competition need to be overcome. Yes, we need uncommon individuals to take this on.

[Chris Ward]

It's not just the USA; different countries in Europe have different ways of organising (and funding) health care, and different sets of outcomes.

The 2 significant advances over the last century have been 'public sanitation' and 'antibiotics'; and even 'antibiotics' might go into reverse as bacteria evolve.

Beyond those, the difference between 'healthcare' and 'automobile manufacture' is that with auto manufacture, you're aiming for a stable process and an identical 'product' each time you turn the crank to make another one. You do process experiments and process changes with a view to improving quality, or reducing cost.

But with healthcare, every person is different.

So it's a challenge.

Can you invest to bring a sustainable income stream ? That is, is it a challenge that a capiialist system can address ?

[Chris Ward]

In the auto industry, it's only the 'manufacturing' stage of the process that has been revolutionised.

As soon as the auto leaves the factory and arrives at the dealership, it's likely to languish on the forecourt waiting for someone to buy it. I believe that the 'benchmark' is 90 days.

Then, after the thing is driven off the forecourt, who knows what is likely to happen to it ?

It's actually quite similar in 'healthcare'. The first stages of a human's life ... up to leaving the mother's womb ... are quite well controlled and predictable, at least in the Western world. The next few stages, too; look at the vaccination schedule, and the proposition that US schools will not accept unvaccinated children.

But after that, the control comes off. Do you look at it as 'loss of quality' ? Or 'diversification and blossoming' ?

[DC Martin]

The challenge in this industry is the difficult issue of profit margin and the recognition that such profit margins are required for necessary investment in productization of innovation. In other industries the very "best" customers account for the greatest profit margin and actions are taken to increase demand. If that paradigm was followed in healthcare we would expect to see a system that forestalls pro-active, pre-emptive care in favor of intensive, expensive last-minute care.

Interestingly, that is what we experience.

If we wish to change the system we must change the timing of the profit margin, spreading it out over the lifetime of the patient. In addition, we must find ways to increase profit throughout the lifetime of the patient so that a long-life is more profitable than a short one.

In addition, if we wish to see innovation delivered to the majority of patients we must recognize that all such innovations must be routinized through the expenditures of early adopters who are self-motivated to spend on such innovations. We do not enable our seniors to participate in both Medicare and be able to choose physicians who do not participate. While this may appear egalitarian, it limits the ability of those who can afford to pay for those innovations.

So all we need to do is identify the parties who stand the make the greatest profit when people live the healthiest and longest lives possible and ensure that our intellectual property systems deliver compensation to those who provide the innovation that will allow us to achieve our objective.

[Anne Johnson]

There are at least three points of approach here, all of them large in scale.

1. Irving's Improve Health System Supply Grand Challenge - how to improve the coordination and delivery of health care.

2. DC Martin's Reduce Health System Demand Challenge - how to use the profit approach to compensate innovations which allow the least possible use of the current health care system while promoting healthy longevity.

Both of these require 'big system' development. There is a third approach, which is actually within the reach of almost everyone - for each individual to take responsibility for consuming no more food energy than the energy they expend over a day or a week. In aggregate this is also a hard problem, running into the profit motives of the fast food, sugar and corn industries. Unlike the others, though, it is possible for each individual to do something, right away, which would make a difference to them.

All of these approaches are required.

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