"Reducing Waste" in Healthcare

A healthcare system needs to be one which "does things for people." Much of our healthcare system today, however, continues to "do things to people," and this is incentivized by our current "fee for service" payment model. The more we "do things to people," the more money we make. The problem with this model is that it is clearly unsustainable.

There is not enough money in healthcare to do everything to everyone. There is not enough money in healthcare, in fact, to do most things to most people. At some point, something has got to give. In my conversations with Great Minds in Medicine, I have brought up the unsustainability of the current system, and a common theme emerges.

When I asked Dr. Rob Bessler about how I, as a critical care physician, can "reduce waste" in healthcare, he said the following:

"It's making sure the right patients are getting the care...life is a terminal illness...and making sure families have those difficult conversations [about goals of care] in advance."

I also asked a similar question to Dr. Greg Johnson , and here is what he said:

“So many other patients are like, ‘No I want to be around my family, I want to be at home’…and engaging in those conversations to understand…that does mean we are not going to be doing certain things...

Both of them meant engaging in goals of care conversations with patients to determine how much care, especially aggressive artificial care, is consistent with their values and beliefs. This is the best way to "reduce waste" in healthcare.

I purposefully put the words "reduce waste" in quotes because, I do not want people to misconstrue what I am saying. I do not want people to think that providing aggressive artificial life support is "wasteful" in my opinion. Far from it.

I am an Intensivist. Providing aggressive artificial life support is part and parcel of what I do, and we do it with a great measure of success. At the same time, if that aggressive artificial life support is inconsistent with my patient's values and beliefs, then it is indeed "wasteful."

For example, if a patient comes to my office with a lung nodule, and she would not want to get either surgery, or radiation therapy, or chemotherapy if that nodule turned out to be cancer, then proceeding with an invasive diagnostic workup is "wasteful." The same goes with a patient in the ICU: if that patient would be upset if he were to see himself in the bed hooked up a ventilator, IV drips, and a feeding tube, then that care is also "wasteful."

That is how having goals of care conversations - which CMS reimburses now - can help "reduce waste" in healthcare. If someone does not want care, then the resources to provide that care can be allocated to someone else who needs that care and wants it. Moreover, it helps provide meaning for us as clinicians as Dr. Johnson noted:

"Engaging [with] our patients in that kind of dialogue suddenly makes us much more compassionate, it does allow us to care for our scarce resources in a way that is more meaningful, and, candidly, brings more meaning to what we do as a healthcare system and physicians within that healthcare system.”

While I am very happy to have goals of care conversations as an Intensivist, and I frequently do have them, these conversations really, really need to be done in the primary care setting, well before a patient becomes ill. And CMS reimburses clinicians now for having those advanced care planning conversations. It is time well-spent, and it will go a long way to help "reduce waste" in our healthcare system.

Listen to the podcast episode: