Brent James and Intermountain Health - Following Rules Improves Care

Tomorrow’s New York Times Magazine  has a thoughtful piece by economics reporter David Leonhart about Brent James, the Chief Quality Officer at Intermountain Health, a hospital system in Utah.  Intermountain is often cited as one of the “high value” health care delivery systems – it has lower complication rates and lower overall costs.   Intermountain, under James’ leadership, has developed detailed “best practice” algorithms for at least 50 conditions representing half of all hospitalized patients, and has gone through the difficult process of convincing doctors that they should follow the rules, rather than their “gut.”

Leonhart points out that in most industries, developing methods to lower the resource costs while maintaining or increasing quality allows growth in market share.   However, under fee for service reimbursement, a hospital like Intermountain loses money when it prevents complications – because it is no longer paid to treat those complications.  For instance, Intermountain says it lost $329,000 by standardizing protocols for inducing labor in expectant mothers (and decreasing babies with premature lungs).  Toyota doesn’t lose money by making cars that were more reliable.  If it did, we would all still be driving AMC Ramblers (a notoriously unreliable car from the 1960s)!

I also appreciate that Leonhart referenced the ongoing debate between those who emphasize the “art” of medicine, like Jerome Groopman, and those who espouse the science like Brent James.  “Cookbook medicine” is not right for every patient, and good physicians know when to deviate from evidence-based rules.  But at least half of all patients are cared for by below average physicians, and populations have better outcomes when physicians follow rules more closely.    Furthermore, the evidence-based rules generally don’t favor the most expensive approach to an individual patient’s treatment.   Comparative effectiveness research could help us enlarge the body of evidence and create more rules.  When physicians and care teams follow those rules, outcomes will be better and physicians can focus on difficult decisions where the evidence is less clear and where their wisdom and expertise will really drive more value for patients.

Much of the change that will decrease the rate of health care inflation has to come in the delivery system (where 85+% of all the dollars are spent).  Intermountain offers the promise of evidence based care that is better and saves money.  Let’s hope the health care reform that passes is able to provide incentives for more organizations to follow this approach.