Pulse

Pulse

Sep 28, 2014

Earth to Mars: Healthcare lessons from India

India's Mars Orbiter Mission last week was remarkable in many respects. India was the first country that successfully sent a spacecraft into Mars' orbit on its first try. The mission took only two years to accomplish from announcement to execution. However, one of Mars Orbiter Mission’s most remarkable aspects was its sticker price. The mission cost $74 million, about three quarters the amount it took to make the Hollywood movie, 'Gravity'.

Health care can learn a few lessons from India. Although healthcare in the U.S. is highly innovative, it is also highly unaffordable. Like technology and manufacturing, the healthcare industry has been experiencing offshoring for the past few years. According to the Centers for Disease Control and Prevention, about 750, 000 Americans travel abroad annually for medical care. A small, but growing number of these patients travel to foreign countries for procedures that are at least partially paid for by their U.S. health insurance plans.

The U.S. and Indian healthcare systems share several similarities. Both large democracies have private and public components to healthcare delivery and finance. Public healthcare is managed by individual states. There are significant urban-rural and socio-economic disparities in healthcare access. Noncommunicable diseases, such as cardiovascular disease and diabetes, are leading causes of death. Special interest groups actively lobby to influence healthcare policies. Medical expenses drive a significant proportion of the population into poverty each year.

There are also significant differences. Even after adjusting for clinician salaries, procedures cost five to ten percent less in Indian hospitals compared to those in the U.S. Out-of-pockets costs for healthcare are far more transparent in India. Defensive medicine is rare. However, India’s infant mortality rate is seven times higher than that of the U.S. Less than five percent of the 2 million Indians who require heart surgery actually receive it. Seventy percent of India’s 8 million blind people would see again, if they could access and afford cataract surgery. Only 36% of the population has sanitation facilities, creating significant public health hazards.

A Harvard Business Review case study of nine innovative hospitals in India, highlights their use of manufacturing and quality improvement principles to reduce costs. Eighty percent of Indians pay for medical care out-of-pocket, compared to ten percent in the US. So keeping costs low is necessary to allow more patients to utilize and pay for healthcare. Indian hospitals purchase costly equipment much less frequently than U.S. hospitals do. They send patients from spoke to hub sites to access resources, reducing equipment idle time and duplication of resources. 

Frugality is the mother of innovation. When one of these nine Indian hospital found that surgeons used only a third of standard length sutures, it ordered packages with shorter sutures. When a hospital was unable to negotiate volume discounts for disposable surgical gowns and drapes, it imported bulk fabric and manufactured its own gowns and drapes, reducing costs by less than half. Expensive single use instruments were rare. Nurses and other staff undertook routine responsibilities, allowing physicians to focus on complex issues. Hospitals developed and performed procedures that cost less. They eliminated unnecessary pre-operative testing. They chose to use cloud-based software for electronic records, rather than building individual computer systems at each hospital.

Now, Indian medical care may be coming to a hospital close to you. Narayana Hrudayalaya, one of the exemplars in the HBR case study, performs open heart surgeries in India at a price of $1500 (compared to $100,000 for the same procedure in the U.S.). Earlier this year, it opened a hospital in the Cayman Islands in partnership with Ascension Health that offers cardiac surgery, joint replacements and neurosurgery for close to half of U.S. prices. Ascension is considering duplicating the model in the U.S. following its Cayman Islands pilot - which seems like an idea worth trying.

- Ulfat Shaikh

Aug 24, 2014

Of Measures and Men

News about the Veterans Affairs (VA) scandal this summer coincided with my being in the midst of reading Daniel Pink’s ‘Drive: The Surprising Truth About What Motivates Us’. Pink’s chapter on unethical behavior seemed uncannily relevant as it described how a carrot-and-stick approach to motivation can encourage cheating, shortcuts and unethical behavior.

The VA reported that patient wait-time data had been falsified in two-thirds of its health care facilities. Organizational leadership failure, an unfocused performance measurement system, a toxic milieu, and unrealistically high goals, that placed undue pressure on staff and promoted unethical practices were cited as key causes.

Several unintended consequences of the VA performance measurement system, mostly related to local implementation methods, were also described back in 2012 by Powell and colleagues.

Performance measurement faces even greater challenges in my own specialty, pediatrics. Pediatric measures tend to be predominantly process measures with sometimes less clear correlations with long-term clinical outcomes and population health. The evidence base for pediatric measures is even less mature than for adult measures, no pun intended.

Performance metrics are essential in tracking outcomes. You can only manage what you measure. And in health care, where demands on scarce resources are increasingly, quality measures are an indisputable way of figuring out which processes need to stay and which can go. Problems begin when performance measures cease to become a means to an end, and become an end unto themselves.

A Robert Wood Johnson Foundation-Urban Institute report advises strategic and parsimonious use of quality measures, recognizing when performance measures are not clinically valid or useful, and recognizing that performance measurement is just one aspect of a learning health care system.

My involvement these days with Central Line-Associated Bloodstream Infection (CLABSI) prevention is demonstrating to me even more strongly the importance of organizational context such as local culture, leadership styles, clinician engagement, and intrinsic motivation in applying quality measures. On hindsight, the training video on CLABSI measures that my team just finished working on probably needed to include a footnote on the perils and pitfalls of performance measurement. And that CLABSI is in essence a social problem that demands a focus not just on tracking infection rates, but on human behavior within complex and intense environments.

Front line clinicians need to remain accountable for their actions. However, leadership and an organizational culture that enforces rigid top-down measures without attention to providing resources and investing in developing people promotes the systemic infusion of unethical behavior and short cuts.

- Ulfat Shaikh



Measuring Improvement in Health Care from Ulfat Shaikh on Vimeo.

May 18, 2014

If I could do one thing to make the world a healthier place

As a pediatrician, it is sobering to realize that the factor with the highest impact on my young patients' health is not a clinical breakthrough. It is whether they and their parents complete high school. Even after taking income or race into account, educational attainment, or the years of schooling an individual has, remains one of the strongest social determinants of health.

People with more years of schooling don’t just prosper. They live longer. They exercise more, eat healthier food, don't smoke, get regular health care, and have better health outcomes. College graduates live at least 5 years longer than people who do not finish high school.

The effect of education is pronounced when you look at female education. Women with

Mar 24, 2014

How to Build a Health Care System from Scratch: Revisiting New Orleans Ten Years Post-Katrina

“My friend was a neurologist at a hospital in New Orleans”, my daughter’s art teacher told me when we were chatting at pick-up time about my upcoming trip to New Orleans. “She lost her home in Katrina”, she continued. “The stories she told me about how they cared for all these patients
in the hospital with no electricity and water and barely any resources were just plain scary”.

My last trip to New Orleans, Louisiana, was in 2003, two years before Hurricane Katrina. My personal agenda for the trip included crawfish, shrimp po’ boys and cafĂ© au lait. Now, more than a decade later

Feb 1, 2014

How a Fishbone Can Help You Eat Your Veggies

February is here and it is possible that a few of you, like me, are already rethinking your new year’s resolutions. What seemed a month ago like a sure-fire plan to lose 10 pounds, exercise more, eat healthier, or manage ones finances, now seems a little more suspect. Let's view this bump in the road, not as a reason for despair, but an opportunity for improvement. 

I teach a class on health care quality called “Personal Quality Improvement”. The class incorporates process improvement techniques