Jake's Journey: Is it the pilot or the plane? Part II


Dr. Bob Crittenden serves as Cambia Grove Executive in Residence and brings a wealth of experience and knowledge as a practicing family physician and as a senior policy advisor. Dr. Bob’s blog series weaves learnings from his career while highlighting broader barriers to health care innovation and possible paths forward. Read more about Dr. Bob and his writings here

Most people receiving health care think their doctor is doing a great job. ‘He or she knows me, understands my needs and ensures I get the best possible care.’ In fact, that is both correct and not correct. Yes, the doctor is doing the best they can in a complicated health system and with the tools available and the doctor does have the patient’s best interest in mind. But many times, the doctor does not have the information and there can be mistakes, facts overlooked or errors due to confusion.

In the first post of this series we talked about a patient named Jake. He wants the best care and trusts his doctor to direct him to it. But his doctor has limits and must rely on charts and reminders to ensure Jake gets that care. Sometimes that support system is not there when Jake needs it. 

Looking from 30,000 feet, health outcomes in America lag behind every developed country. These comparative measures show that Americans spend more time being disabled, more often die before their expected time and on average die five years younger than similar patients in peer countries from conditions amenable to treatment. 

The Problem  

We do not provide and fund many of the proactive solutions  for people in our community with behavioral and social problems that are huge drivers of health outcomes. 

And, we have a health system with incentives and a structure that is inefficient and rewards doing more ‘things’ rather than doing better. Volume over quality has become the norm.

The incentives and structure of our health system are improving, but similar to our health outcomes, lag many of our peer countries. Historically, great improvements were made in industries that moved from blaming failures on participants, to examining bad outcomes as potential system failures. The airline industry moved from blaming pilots to looking at the systems responsible, and ultimately improved their planes. When there is a failure in the airline industry, maximum effort support root cause identification, and the follow-up is focused on developing systems where the same error will be avoided. 

In health care in the US, we know we have good doctors and providers. Yes, an occasional bad actor, but almost all doctors, nurses and other providers want to and do provide the best care. Where we fail is having systems that backstop and support providers in known problem areas (e.g. harmful procedures, conflicting medications, missed prevention). 

Addressing Problems: 

The evolution of written prescriptions is a great system evolution success story. Not long ago doctors wrote all prescriptions out long-hand resulting in pharmacists having to call the doctor if they could not read the script – or if it looked legible, occasionally filling Jake’s  prescription with the wrong drug or directions. Electronic prescriptions have eliminated many errors - now the error rate is one seventh the amount as before electronic prescribing – and this change decreased health costs by about $140-240 billion over 10 years.  

Another still-evolving example is our payment system for providers. While no doctor knowingly provides services that are of no value, there is a gray area where doctors use judgement - and anyone’s judgement can be affected by their organization’s culture and incentives. Many studies have shown that 30-40%  of the services provided are of little or no value to patients like Jake. The cost of care is less in systems where incentives are aligned with outcomes and reward lower cost for equally effective alternatives - and quality improves (more prevention and fewer side-effects from ineffective services).

If we want increased quality (healthier outcomes) and decreased costs, we need to align our payments and incentives to achieve these goals.

And, we need to align those incentives in a straightforward and streamlined way that does not further complicate the lives of care providers.   

In the administrative realm, billing and insurance activities cost American consumers tens of billions of dollars per year. This one category is 1.9% of France’s health expenditures and 7.3% of the US national health expenditure. Our transactional costs are high and redundant due in large part to fragmented systems with complex requirements for payment.   

In the operational parts of the health system, duplication of services, inefficient processes, expensive inputs and errors dominate the waste. Our patient Jake  may need to correct his bill or remind his physician of his knee procedure last year – issues indicative of pervasive system issues. Addressing any of these areas can improve outcomes and reduce costs. As in the prescription example above, backstops that assure appropriate care can improve outcomes and save money.

In clinical issues, services that are cost ineffective (e.g. same outcome with higher cost) and those that are detrimental to health, lead the list for issues that need intervention. Health care is complex and any time we can decrease that complexity, provide alerts for potential errors and provide information on most effective approaches to problems, we will decrease unforced errors. There is a national effort to identify processes and services that are considered by studies and the medical profession to be completely wasteful. In Washington state, the Washington Health Alliance did an analysis and found that when looking at just 47 possibly overused services – 1.3 million people in the state (out of 7 million) received one of these services and about half of those services were ineffective, considered waste and not helpful to the patient. There is a lot of room for improvement.   

Next Steps

Innovations that can address administrative waste, fragmentation, transactional costs, improved operations, poor quality services and completely ineffective services can have an immediate positive impact on the health care system. Providing frontline doctors with tools that help them provide the best quality care are a must. In addition, 

connecting social and behavioral services with medical services – like assuring high risk and vulnerable patients stable housing – can improve health outcomes and save money in the system.

Our patient Jake does not know if his care is better than other countries or not, and if he’s like most Americans, he won’t have comparison opportunities. He trusts his doctor to guide him through this wilderness we call the health care system. Doctors, health systems and innovators all need to rise to the occasion, innovate and improve the systems we work in and Jake needs. We need to use technology and improved systems to decrease our error rate and make our plane safer.


About Dr. Bob Crittenden

Dr. Bob Crittenden joined the Cambia Grove as the first-ever Executive in Residence. He has practiced as a family physician for over 28 years in central and southeast Seattle with urban underserved populations, worked for the state legislature, been a Robert Wood Johnson Health Policy Fellow with Senator George Mitchell, was special assistant to Governor Gardner for health, and is a Professor Emeritus in the Departments of Family Medicine and Health Services at the University of Washington.

His work on projects at the local, state and national levels focuses on improving the access and effectiveness of health services for all populations. Most recently, he served as Gov. Jay Inslee’s Senior Health Policy Advisor, where he was instrumental in the implementation of the ACA in Washington state and the successful Medicaid Transformation Waiver. He has also played a key role in initiating the Kids Get Care program, actively participating in rural and urban underserved health systems improvements, and working with insurers, employers and providers in improving systems of care for chronic conditions.

Dr. Crittenden received his BA in Communications and Public Policy from the University of California, Berkeley and a diploma in Political Theory and Development Economics from Oxford University. He went on to earn his Medical Degree at the University of Washington School of Medicine and his Masters of Public Health in Health Services from the University of Washington. He loves any sport and enjoys his time on the lake or in the mountains.


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