Is There a Doctor in the Kitchen?

     Anyone who reads my blog knows that I don't hesitate to moan and groan about the high cost of health care and medical insurance. In my defense, part of the reason is that, as an early retiree, I'm part of a minority of Americans who pay the full cost of their own medical insurance. I'm not among the majority of public workers, corporate employees and Medicare-covered seniors who typically pay only 10 - 20% of the real cost.

     The other reason (according to my kids, at least) is that I'm cheap.

     But part of the reason I'm cheap is because, for the past ten years, ever since I was forced into early retirement, that monthly health-insurance bill has eaten up a big chunk my income (along with college tuition, but that's a whole other issue).

     So I ran across an interesting article in last week's New Yorker, "Big Med" by Atul Gawande, that makes an interesting case for how we might control medical costs and improve results as well. Dr. Gawande is a surgeon at Brigham and Women's Hospital in Boston, a professor of surgery at Harvard Medical School, and a staff writer for The New Yorker.

     One Saturday the doctor dines at the Cheesecake Factory, and he wonders why a medical facility can't operate more like a chain restaurant -- one that serves 80 million people a year with over 300 menu items, and where most dishes are made from scratch and the waiters are efficient and friendly.

     Restaurants have been able to bring the efficiencies of chain production to the complicated business of serving sit-down meals, but medicine still operates like a collection of "mom and pop" stores. Unlike the Cheesecake Factory, medicine has been "unable to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality."

    Chain restaurants have an advantage over small independents because they are big enough to enjoy buying power, they can centralize common functions, and they adopt innovations faster than a random group of individual restaurants.

     Doctors have historically worked for themselves or as part of small groups. Hospitals were community based. Doctors have traditionally billed patients for services rendered, and they therefore have had various incentives to order more, unnecessary tests and procedures, to pad their bills, practice defensive medicine or to satisfy nervous test-seeking patients.

     But in the last decade, Gawande notes, more and more doctors have begun to join larger medical groups or else sign on as employees of hospitals that are merging into larger hospital chains. Hospitals are beginning to benefit from economies of scale, and they increasingly sign contracts with Medicare and the insurance companies to be paid not on the number of procedures performed, but on the basis of how well they meet certain cost-reduction and quality-improvement targets.

     What especially struck Gawande about the Cheesecake Factory was that there are precise instructions that cover the ingredients of all the menu items and their presentation. But each cook has considerable leeway about how to turn the ingredients into the final product. Plus, each restaurant has a kitchen manager who checks the final product, making sure that standards are being met. Managers are respectful of a cook's skills and experience, but oversight is fairly tight. There are guidelines for how many employees a restaurant should have, based on the number of customers, as well as strict measures of how much waste can be tolerated. The company target is 97.5% efficiency -- in other words, they throw away only 2.5% of the food they purchase. (Think about your own kitchen, and how much of the food you bring home form the grocery store gets thrown out.)

     A common complaint among medical patients is that they are shuffled from specialist to specialist, with no one person taking overall responsibility for their care. Gawande says that hospitals would benefit from "kitchen managers" who are responsible for getting clinicians to agree on precise standards of care, making sure that they follow through on them, and ensuring that the final results maintain the agreed-upon standards.

     Gawande notes, for example, that there is no standard practice for knee surgery. Even within the same hospital, different doctors use different makes of artificial knees; they use different procedures, different protocols for anesthesia, different strategies for post-operative pain management and physical therapy. There is no organized effort to identify the best products and procedures, then figure out how to standardize them and disseminate them to a broad range of medical practitioners.

     There should be one best standard way to do knee replacements -- or any other medical procedure -- a method that everyone follows. Beyond that, he argues, customization should be 5% of what the doctors do, not 95% of what they do.

     In medicine, new procedures have traditionally taken a long time to trickle down to the majority of patients. He cites the example of beta-blockers, used after a heart attack. It took some 15 years between the time the studies confirmed the benefit, and the time the majority of Americans were offered the new treatment.

     But the Cheesecake Factory puts out a new menu every six months. It takes them only seven weeks to roll out the new menu, including finalizing recipes, purchasing and distributing the new ingredients, changing the menus and training the staff.

    Gawande admits there is no guarantee that increased size and tighter controls will improve medicine and bring down costs. Sometimes bigger institutions lead to monopolies that raise prices, stifle innovation and benefit owners rather than customers. But he feels that larger, more uniform medical organizations, following standardized rules and regulations, with some government oversight as well as transparent methods that are open to public scrutiny, could provide better, more consistent care for everyone, at lower cost. Just like the Cheesecake Factory.

     If you don't want to read the full, lengthy New Yorker article cited above, try this npr interview with the doctor from last week.

     As for me, I've never been to a Cheesecake Factory. I googled it. There's one a little over 20 miles from my house. Dr. Gawande makes it sound good -- I'll have to go try it out.