No one wants to hear Odysseus go to the corner store.
– Alex Blumberg
Recently, I was sent an interesting article about how “Cowboy(/girl)” doctors are driving up healthcare costs in medicine. The authors cite a study that argues that, when it comes to dying, certain doctors “reject ‘evidence-based professional guidelines for appropriate care’ and… order invasive and costly procedures despite little chance their efforts would delay the inevitable”. These “Cowboy” doctors, as they are labeled, contribute up to 35% of end-of-life fee-for-service Medicare expenditures, and up to 12% of overall Medicare expenditures. To give you an eye-popping dollar figure, that would amount to $84.5 billion.
Beyond questions of morality and what constitutes “little chance” in the study, this raises another interesting question for patients and providers: should we drive toward standardization of care plans?
On the one hand, the word standardization itself implies, at the very least, a reduction in inequality for all. But furthermore, recent studies of standardization of care across patient populations shows it cuts costs and raises quality, two front and center goals of the IHI’s Triple Aim. In business school, we had a saying in strategy: “No customization without differentiation”. Basically, I took this to mean that unless you could prove beyond a doubt that your special snowflake was far superior to the rest, you should not customize the product/company/service you were offering. Bundled payments programs like CMS’s Comprehensive Care for Joint Replacement (CJR) aim to use standardization to drive improved outcomes and cost, perhaps implying that they believe current customizations between providers are not differentiated.
However, standardization of care (often through the specter of “socialized medicine”) is a common boogeyman evoking images of “death panels”, rationing, and the removal of physician judgment from the medical process. Obviously, depending on how the problem is framed public opinion shifts, and there are different care delivery models that can make these problems better or worst.
As we enter HIMSS19 this week, and we start to see more intelligent offerings that aim to bring standardized, evidence-based practices to global healthcare delivery, I can’t help but hearken back to when the human genome was first sequenced. The attitude back then, growing up in a family of physicians, was that from that day on every single treatment would be individualized and targeted. No longer would your Advil bottle say “Adults over 12 take two pills per day”, and gone were the days of treating every infection with Amoxicillin. But now, we have done a complete U-turn. HIMSS vendors and attendees are focused on treating populations of thousands or millions of patients with reduced variation, reduced cost, and greater predictability. Not greater customization.
In fact, I was in a conversation at Cerner last week where we began to touch on some of our advanced genomics offerings. One business leader remarked that there were well-set standards in pharmacogenomics, but fewer in oncological genomic medicine. This focus on standards led me to think that there may be a new two-tiered approach emerging in medicine. First, advanced medical practices are studied and honed at leading specialty centers (for example, MD Anderson for cancer). Then, they are formulated into practices that are proven to scale to thousands or millions of patients in a repeatable manner.
It’s a far cry from the precision offered by gene sequencing and individualized treatment, and more akin to the University -> Industry pipeline that has existed in the tech industry for years (think Stanford PageRank -> Google Search). I don’t know what to make of this yet, but I think there are implications that we need to think through:
- Will the drive toward standardization compound the problem of ignoring rare illnesses, which the U.S. had to combat with special Orphan Drug regulations?
- Will the rise in standardization cause a loss of provider autonomy and worsen the problems of burnout and disengagement U.S. clinicians face?
- Is the human body and its millions of variations even “standardize-able” in such a way that allows this approach to work?
Either way, technology has a role to play. But I always worry about pendulum swings, and my take is that competing approaches should be balanced to find an optimal path.
 See the HHS 2018 budget in brief for more details.
 I’m looking for a comprehensive article or journal paper discussing the systemic effects of rationing in single-payer, integrated delivery systems, and different competitive models but I can’t find anything good. Let me know of any good links.