I just came across a blog note by a radiologist, J. Raymond Geis, reacting to Atul Gawande's recent article in the New Yorker about what he calls "Big Med." By this he means the standardization of medicine from the current local, highly customized model to a more corporate model similar to that used in the restaurant chain called the Cheesecake Factory (see: Cheesecake Medicine: Is Radiology Ready for Big Med?). Here is an excerpt from Geis's note:
The Cheesecake Factory restaurant model represents our best prospect for reliable, high-quality, affordable medicine. Up to now we've let healthcare systems provide us with the equivalent of greasy-spoon fare at 4-star prices, and the results have been ruinous. So says Atul Gawande in a recent New Yorker article, "Big Med," which is generating discussion throughout the US healthcare community. Big Med will arrive throughout the US, no matter what happens with the election....Healthcare is behind other industries in this change, just as it lags in informatics. Healthcare is a cottage system, like restaurants and retail business used to be....No single entity is in charge, and no cost objectives, efficiency standards, or safety goals exist for the overall system. They also note that one cannot optimize a large, complex system by optimizing its individual parts because that does not account for interactions among those parts. Healthcare even has cottages within cottages. Each subcomponent is independent. Within a hospital the radiology IT department often acts as an independent cottage to optimize its own quality and productivity outside of plans by the larger entity. Medicine is also, however, what engineers call a complex adaptive system. That means it isn't as straightforward as, say, the restaurant industry. A complex adaptive system's behavior is often unpredictable, and no one is "in charge." System behavior is more easily influenced than controlled. Medical imaging is moving towards Big Med. This will require a whole new world of imaging informatics. Not only must imaging informaticists implement software to manage and measure quality and standardize and optimize workflow. This software must do more than improve tasks in our own imaging cottage; it should be part of the bigger picture of health information technology.
For me, here is what I consider the money quote from the New Yorker article:
Today, some ninety “super-regional” health-care systems have formed across the country—large, growing chains of clinics, hospitals, and home-care agencies. Most are not-for-profit. Financial analysts expect the successful ones to drive independent medical centers out of existence in much of the country—either by buying them up or by drawing away their patients with better quality and cost control....[A]nalysts expect that most of us will gravitate to the big systems, just as we have moved away from small pharmacies to CVS and Walmart...Cleveland Clinic...opened nine regional hospitals in northeast Ohio, as well as health centers in so.uthern Florida, Toronto, and Las Vegas, and is now going international, with a three-hundred-and-sixty-four-bed hospital in Abu Dhabi scheduled to open next year. It reached an agreement with Lowe’s, the home-improvement chain, guaranteeing a fixed price for cardiac surgery for the company’s employees and dependents. The prospect of getting better care for a lower price persuaded Lowe’s to cover all out-of-pocket costs for its insured workers to go to Cleveland, including co-payments, airfare, transportation, and lodging...Big Medicine is on the way.
Big Med should not be confused with a term that I used in previous blog notes, Big Medicine, by which I meant the strategic collaboration of large hospitals and hospital chains, pharmaceutical companies, health insurance companies, and payers such as the U.S. government and large corporations (see: Physician Private Practice Declines; the Last Barrier to Emergence of "Big Medicine"; Big Pathology, Multi-Specialty Groups Versus Small; Which Way in the Future?). Germane to this same topic, take note of the proposed and recently announced $6.4B merger of two large hospital systems in the southeast Michigan market market, Beaumont and Henry Ford (see: Simple economics behind merger push for Henry Ford, Beaumont).
I think that Gawande is generally correct in his assessment. Large “super-regional” health-care systems will compete aggressively on price and drive smaller hospitals out of business or force them to affiliate with these very large health systems. All of us need to ponder how this will change healthcare delivery as it exists today. I will return in future notes to the point made by Dr. Geiss above regarding the role of critical pathology and radiology informatics in this transition to Big Med.