Not Like LLBean

This week I received an email from the leadership at my hospital, encouraging me to contact my elected (Maine) state representatives in support of some pending legislation to force the State to finally pay the hospital millions of dollars in unpaid obligations from previous years. While there was no question that the hospitals are owed the money, a comment in the appeal stopped me in my tracks and ultimately made me decide not to email my legislator.

After listing a number of external financial setbacks like sequestration, changes in Medicare and Medicaid policies and payments, the recession, and the debt the State of Maine has not paid off during the last few years, the appeal claimed “that we are doing what we can to reduce our operating costs.”  That’s where they lost me.

US health care institutions (I am not singling out my hospital here) evolved to do a different job in a different scientific, cultural and financial environment and have failed (refused would be a better word) to adapt to the 21st Century. We are using the wrong (cumbersome and expensive) tool for the job. Let me give an example.

If you want to know whether LLBean has a shirt in stock in your size and preferred color (you saw your neighbor wearing it at dinner this evening and your wife said it was neat),  you visit their site, click Men, click shirts, scroll, see the shirt, and click and…Voila…your answer. You can do this for free at 3 pm or 2 am, at home or at work, with a computer, with your smart phone or tablet, during dinner at Fishbones, while watching your son’s soccer game, or even while your wife is driving you to work. It takes less than a minute and most 8 year olds can do it. What's more, if you want to buy the shirt, you click on the 'Add to shopping cart' icon and it uses your stored address and billing information, charges your card, sends you an email notification of the purchase and another when it is shipped, and allows you to see tracking information. The shirt is shipped without further work on your part. Another 30 seconds.

In contrast, imagine you have a similarly simple task you wish to accomplish with your PCP. Perhaps you want to know if you can take Drug X once daily instead of twice daily. You have been taking it for 5 years, prescribed by your PCP. Simple question. You know what happens next:

  • You have to call during weekday business hours and may not be able to call during lunch, depending on the office.
  • You will certainly encounter a telephone tree that lasts longer than the entire LLBean interaction, including purchase.
  • You will be routed either to a receptionist or to voice mail, depending on the office and how busy they are at that moment.
  • Assuming you are lucky and are forwarded to a person (we'll skip voicemail for now - it is exponentially worse than this scenario and will appear later in this nightmare), you may be on hold for as little as a few seconds or as long as 10 minutes. 
  • When you finally talk to a receptionist, she asks you who you are, verifies your phone number and perhaps DOB and there is a delay of seconds or minutes while she finds you in the computer. (At LLBean, you were recognized automatically when you hit the page: Welcome back, Jim.) She then asks you what your questions or concerns are and types an incomplete and likely inaccurate version (because she is not medically trained) into a phone message and tells you a nurse will call you back. She may try to estimate when. If she does, she may be in the right ballpark. Or not. It may be 20 minutes or 6 hours. She routes the message to a nurse.
  • The nurse tries to reach you between rooming patients and other tasks, but you are in the bathroom or on another call, so a message is left. You get that message and call the nurse back, now that you know her extension. She is rooming a patient so you leave a message on her voicemail. (See - I told you we'd get to the voicemail.) Later in the afternoon she tries again and you are on the way home and miss the call. She leaves a message that she called and routes the message to the after hours staff who try to reach the people missed during the day. 
  • The after hours staff reaches you during dinner at 6:10 and you get to repeat your question again. The nurse corrects the truncated and garbled version she sees in the phone message and tells you that your PCP has gone home for the day but that she will send the message to his desktop and he will review it, send it back to her and she will let you know. She forgets to tell you he is off the next day. (Or perhaps it is Friday.)
  • Because you thought you would hear the next day and did not, you call back to make sure the message was not lost. After the telephone tree connects you to a receptionist and she looks it up, you learn it is on your PCP's desktop and he will be back tomorrow and address it.
  • The next day (which may actually be 4 or 5 or more days after you first called) your PCP sees the message and types her simple answer: "Sure. If you want, we can change to the long acting preparation and you can take one slightly bigger pill once daily." Routes it to her nurse.
  • Now telephone tag begins again. This time you are lucky because it only takes 2 days to get the message. You would like to change to the extended release, so a new message is generated for the PCP, who then changes it on your med list and sends a prescription electronically to your pharmacy which notifies you the next day to pick it up.

(We will assume that there are no extra volleys of messages about what pharmacy, whether you want 30 or 90 days, issues of prior authorization, or an additional question you have thought of or your wife wants you to ask - each of which could generate its own entire series just like this.)

Not like LLBean, right?  This is a real episode. It is not made up or an exaggeration. It happens quite literally hundreds of times every single day in every single PCP office. I could supply the world’s stand-up comics with 10 year’s material with examples. Do you have any idea of how much staff time is consumed with this sort of waste? There are numbers, which I will not waste space on here.  Our hospital promised secure electronic communication between providers and patients about 7 years ago but has still not put anything in place. There are tools do secure communication within our EHR (Centricity). There is good data that using secure communication saves 1-2 hours of nursing time per provider every day. And improves safety, quality and patient satisfaction. And enhances revenue.

Whenever I see or hear representatives of medical institutions talk about how hard they are working to get lean and reduce operating costs, I have to laugh. (Remember, my hospital is NOT alone.) Because the alternative is to cry. Yes, operating costs are being squeezed: hiring freezes, replacing higher with lower trained workers, no raises and reduced benefits (that inevitably hit the lowest wage workers the hardest), delayed purchase of the tools that would increase quality and efficiency, lower quality materials, closing programs that are cost but not revenue centers regardless of their medical value. Some short term gains are made but the non-financial cost is huge, and the elephant remains standing in the center of the room. 

At least 75% (and probably closer to 90%) of what we do in PCP offices every day could be done at a fraction of the cost if it weren't being done by a tool that has evolved for good reason over a long time to do an entirely different set of tasks.  You would never think of driving a backhoe to the store to pick up your groceries, but that is exactly what we are doing, using a system designed to support a trauma center and an air ambulance and an ICU and oncology center and armies of non-clinical do primary care.

I could list lots of examples of institutionalized complex wasteful processes, like patient access to records, many clinical protocols when applied poorly or in the wrong setting, or making appointments. Another post, perhaps.

We have carefully and obediently followed all of the standard MBA teachings and management best practices and created an institution-centric cumbersome and expensive health care machine that tries to do too many disparate things, does some of them exquisitely well, but also does many of them poorly and only few of them efficiently.  No matter how much they fix Medicare/Medicaid or the SGR or sequestration, our current system evolved for a world that is long gone. It cannot thrive and may not survive in the current environment. People like Clayton Christensen, Clay Shirky, Paul Levy, Donald Berwick, Richard Bohmer, Paul Nunes and Larry Downes, Dave de Bronkart, Larry and Lincoln Weed, Gary Hamel, William Baumol, Paul Argenti, and Etienne Wenger have very valuable things to say about this problem. US healthcare is not listening. My hospital is not listening. And I don’t feel comfortable asking my State government to throw good money after bad. 




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