from the world's big
How to Not Punish Hospitals for Good Care
Atul Gawande is a general surgeon at Brigham and Women’s Hospital and, since 1998, a staff writer for The New Yorker. In 2006, he received the MacArthur Award for his research and writing. His book "Complications: A Surgeon’s Notes On An Imperfect Science" was a finalist for the National Book Award in 2002 and is published in more than a hundred countries. His newest book, "The Checklist Manifesto," is one of Amazon’s best books of the month: December 2009. He and his wife, Kathleen Hobson, live outside Boston and have three children: Walker, Hattie, and Hunter.
Question: Is there enough room for medical experimentation in the current health reform bill?
Atul Gawande: Yes and no. So if this health reform bill goes through, and I think it's looking like every sign will, it is about health reform, but not reforming health care, which is what we really need; meaning redesigning health care to be better quality, better safety, lower cost, getting rid of wasted, unnecessary steps and moves and the harmful components of care. It has the experiments in it to be able to start having us try to innovate on that systems level. So when we've talked about innovation in medicine, what we've usually meant is, will there be a new drug? Will we have a cure for cancer? And we are on our way, with or without reform, to spending 18, 19, perhaps even 20 percent of our whole economy on health care. There's no shortage of money for those kinds of innovations, and I think those fields will prosper. But to take advantage of them and be sure we're using them in every community in the right way, at the right time, we have not been innovating. I think if health reform doesn't pass that we will be very slow to innovate.
But there are components in the health reform package that include innovations both at that front end, trying to design, say, the checklists for the right kind of care, and also on the incentives end. That is, one of the reasons we don't come up with these kinds of checklists is that hospitals and doctors don't do better financially when they put in these kinds of tools. For example, Children's Hospital in Boston came up with a checklist for asthma patients, children who are severely asthmatic enough to end up admitted to the hospital. And they recognized that a couple of components were key: making phone calls to the families to make sure the children were taking their inhalers, and having a look at their apartments to make sure that -- or homes -- to make sure that dust and mites were not a problem in the homes. By tackling just those two things, they reduced admissions for kids with asthma by 87 percent. But asthma was their number one admission to Children's Hospital. And the found this experiment lost them millions of dollars. And so they suddenly were face to face with, well, maybe we need to shut down this program in order to survive as a hospital. That's when you know there's just something wrong with the way we are designing our system.
And the reform bill -- we don't know what is the best way to pay that hospital so that it does the right thing, but we have some good ideas about the experiments to try. One is, for example, paying the doctors and hospital together, whether that kid is admitted to the hospital or not, so that they're on the same page about taking care of this kid with asthma. The kid with asthma might get -- I don't know; I'm pulling a number out of the hat -- $5,000 for that diagnosis and care in that year. And so let's simply give that money and then have them work to try to make the best of that financial situation, which I think leads -- can lead -- to better care.
Question: Is the Massachusetts health care system working?
Atul Gawande: What's right about the Massachusetts system is coverage. We went from 12 percent uninsured to 2 percent uninsured, and that's very impressive. European countries are at 98 to 99 percent coverage of their populations, and Massachusetts did it without -- with most of the people in the population not even noticing. It was through private coverage; basically, if you are uninsured or can't afford insurance coverage, you can go on the Web and get subsidized insurance policies that limit your costs to about 8 percent of your income. Not everybody's happy about that. If you're only earning $30,000 a year and have $2400 -- that's 8 percent -- to have to pay, that seems like a lot. But insurance premiums are typically 15 or 16 percent of people's income, so it's heavily subsidized.
The down side: cost. There was nothing in the Massachusetts plan to deal with costs. Now, the costs have not -- contrary to many of the news reports -- have not outstripped the budget. The Massachusetts health care costs have continued to rise about 8 percent or so per year, which is right in the middle of where the country's costs have been rising. And the program for the uninsured actually came in under budget. If the recession hadn't dropped the bottom out of tax revenues, then this would have gone on as if there were no issues at all. But the pressure of the loss of that tax revenue led the hospitals and doctors and insurers to actually be serious about cost controls. And I'd say in the state we're a couple years ahead of other places in starting to try innovations, paying doctors and hospitals differently. Instead of fee-for-service, just being paid for every time you do an operation, for example, there's a shift towards saying, let's pay for results, and let's figure out how to do it. So that kind of pay-for-results system is now being tested and experimented with, though it's still not easy to figure out.
Question: What are the biggest advantages being proposed in the current healthcare reform package?
Atul Gawande: The national reform package actually looks a lot like the Massachusetts package. It has coverage through private insurers that people would get to choose from -- go on the Web and sign up for a health plan if you don't have coverage or can't afford it. There's more in the bill to do with trying to control the costs, and that is also a plus. There's more in there than we see in Massachusetts by far. Some of it is to try to really drive insurance competition by, for example, having insurers pay a premium tax if their insurance plans comes to cost more than $23,000 a year. Most plans are far from costing that much right now, but they're on their way to doing it if they don't figure out how to organize better.
Second, though, is whether it's private insurance or federal programs like Medicare, there are very interesting experiments, pilot programs, to test out paying doctors in different ways from the way we've done it; for example, paying a hospital system that actually encompasses both hospital care and outpatient care -- what they call gain sharing. If they bring their costs down, the Medicare program would let them keep half of the reduction in costs, to try to provide an incentive for controlling costs, as long as they meet basic quality control measures and have good access to primary care. Can hospitals actually learn to do this? Can we organize to get our act together? I think the answer is going to depend on their adopting things like checklists for the most costly and harmful conditions, where we see a lot of mistakes and waste. But this is tough stuff. Doctors and hospitals are quite fragmented, very disorganized, and learning how to really work as a system of people is going to take us -- it's not going to be a matter of two or three years; this is going to be a generational effort. But I think the clear signs are, we can first end up reducing just the rate of inflation, but then over time if we are able to learn and use the lessons, we could even bring the cost down, which has been feasible in other lines of work.
You can tell a system is broken when a prominent children’s hospital devises a system that reduces local asthma cases by 87%, but then has to cancel the program due to the lack of revenue from new and recurring patients. Can the current healthcare reform bill end this ridiculous approach?
Higher education faces challenges that are unlike any other industry. What path will ASU, and universities like ASU, take in a post-COVID world?
- Everywhere you turn, the idea that coronavirus has brought on a "new normal" is present and true. But for higher education, COVID-19 exposes a long list of pernicious old problems more than it presents new problems.
- It was widely known, yet ignored, that digital instruction must be embraced. When combined with traditional, in-person teaching, it can enhance student learning outcomes at scale.
- COVID-19 has forced institutions to understand that far too many higher education outcomes are determined by a student's family income, and in the context of COVID-19 this means that lower-income students, first-generation students and students of color will be disproportionately afflicted.
What conditions of the new normal were already appreciated widely?<p>First, we understand that higher education is unique among industries. Some industries are governed by markets. Others are run by governments. Most operate under the influence of both markets and governments. And then there's higher education. Higher education as an "industry" involves public, private, and for-profit universities operating at small, medium, large, and now massive scales. Some higher education industry actors are intense specialists; others are adept generalists. Some are fantastically wealthy; others are tragically poor. Some are embedded in large cities; others are carefully situated near farms and frontiers.</p> <p>These differences demonstrate just some of the complexities that shape higher education. Still, we understand that change in the industry is underway, and we must be active in directing it. Yet because of higher education's unique (and sometimes vexing) operational and structural conditions, many of the lessons from change management and the science of industrial transformation are only applicable in limited or highly modified ways. For evidence of this, one can look at various perspectives, including those that we have offered, on such topics as <a href="https://www.insidehighered.com/digital-learning/blogs/rethinking-higher-education/lessons-disruption" target="_blank">disruption</a>, <a href="https://www.nytimes.com/2020/02/20/education/learning/education-technology.html" target="_blank">technology management</a>, and so-called "<a href="https://www.insidehighered.com/sites/default/server_files/media/Excerpt_IHESpecialReport_Growing-Role-of-Mergers-in-Higher-Ed.pdf" target="_blank">mergers and acquisitions</a>" in higher education. In each of these spaces, the "market forces" and "market rules" for higher education are different than they are in business, or even in government. This has always been the case and it is made more obvious by COVID-19.</p> <p>Second, with so much excitement about innovation in higher education, we sometimes lose sight of the fact that students are—and should remain—the core cause for innovation. Higher education's capacity to absorb new ideas is strong. But the ideas that endure are those designed to benefit students, and therefore society. This is important to remember because not all innovations are designed with students in mind. The recent history of innovation in higher education includes several cautionary tales of what can happen when institutional interests—or worse, <a href="https://www.insidehighered.com/news/2016/02/09/apollos-new-owners-seek-fresh-start-beleaguered-company" target="_blank">shareholder</a> interests—are placed above student well-being.</p>
Photo: Getty Images<p>Third, it is abundantly apparent that universities must leverage technology to increase educational quality and access. The rapid shift to delivering an education that complies with social distancing guidelines speaks volumes about the adaptability of higher education institutions, but this transition has also posed unique difficulties for colleges and universities that had been slow to adopt digital education. The last decade has shown that online education, implemented effectively, can meet or even surpass the quality of in-person <a href="https://link-springer-com.ezproxy1.lib.asu.edu/article/10.1007/s10639-019-10027-z" target="_blank">instruction</a>.</p><p>Digital instruction, broadly defined, leverages online capabilities and integrates adaptive learning methodologies, predictive analytics, and innovations in instructional design to enable increased student engagement, personalized learning experiences, and improved learning outcomes. The ability of these technologies to transcend geographic barriers and to shrink the marginal cost of educating additional students makes them essential for delivering education at scale.</p><p>As a bonus, and it is no small thing given that they are the core cause for innovation, students embrace and enjoy digital instruction. It is their preference to learn in a format that leverages technology. This should not be a surprise; it is now how we live in all facets of life.</p><p>Still, we have only barely begun to conceive of the impact digital education will have. For example, emerging virtual and augmented reality technologies that facilitate interactive, hands-on learning will transform the way that learners acquire and apply new knowledge. Technology-enabled learning cannot replace the traditional college experience or ensure the survival of any specific college, but it can enhance student learning outcomes at scale. This has always been the case, and it is made more obvious by COVID-19.</p>
What conditions of the new normal were emerging suspicions?<p>Our collective thinking about the role of institutional or university-to-university collaboration and networking has benefitted from a new clarity in light of COVID-19. We now recognize more than ever that colleges and universities must work together to ensure that the American higher education system is resilient and sufficiently robust to meet the needs of students and their families.</p> <p>In recent weeks, various commentators have suggested that higher education will face a wave of institutional <a href="https://www.businessinsider.com/scott-galloway-predicts-colleges-will-close-due-to-pandemic-2020-5" target="_blank">closures</a> and consolidations and that large institutions with significant online instruction capacity will become dominant.</p> <p>While ASU is the largest public university in the United States by enrollment and among the most well-equipped in online education, we strongly oppose "let them fail" mindsets. The strength of American higher education relies on its institutional diversity, and on the ability of colleges and universities to meet the needs of their local communities and educate local students. The needs of learners are highly individualized, demanding a wide range of options to accommodate the aspirations and learning styles of every kind of student. Education will become less relevant and meaningful to students, and less responsive to local needs, if institutions of higher learning are allowed to fail. </p> <p>Preventing this outcome demands that colleges and universities work together to establish greater capacity for remote, distributed education. This will help institutions with fewer resources adapt to our new normal and continue to fulfill their mission of serving students, their families, and their communities. Many had suspected that collaboration and networking were preferable over letting vulnerable colleges fail. COVID-19's new normal seems to be confirming this.</p>
President Barack Obama delivers the commencement address during the Arizona State University graduation ceremony at Sun Devil Stadium May 13, 2009 in Tempe, Arizona. Over 65,000 people attended the graduation.
Photo by Joshua Lott/Getty Images<p>A second condition of the new normal that many had suspected to be true in recent years is the limited role that any one university or type of university can play as an exemplar to universities more broadly. For decades, the evolution of higher education has been shaped by the widespread imitation of a small number of elite universities. Most public research universities could benefit from replicating Berkeley or Michigan. Most small private colleges did well by replicating Williams or Swarthmore. And all universities paid close attention to Harvard, Princeton, MIT, Stanford, and Yale. It is not an exaggeration to say that the logic of replication has guided the evolution of higher education for centuries, both in the US and abroad.</p><p>Only recently have we been able to move beyond replication to new strategies of change, and COVID-19 has confirmed the legitimacy of doing so. For example, cases such as <a href="https://www.washingtonpost.com/education/2020/03/10/harvard-moves-classes-online-advises-students-stay-home-after-spring-break-response-covid-19/" target="_blank">Harvard's</a> eviction of students over the course of less than one week or <a href="https://www.nhregister.com/news/coronavirus/article/Mayor-New-Haven-asks-for-coronavirus-help-Yale-15162606.php" target="_blank">Yale's apparent reluctance</a> to work with the city of New Haven, highlight that even higher education's legacy gold standards have limits and weaknesses. We are hopeful that the new normal will include a more active and earnest recognition that we need many types of universities. We think the new normal invites us to rethink the very nature of "gold standards" for higher education.</p>
A graduate student protests MIT's rejection of some evacuation exemption requests.
Photo: Maddie Meyer/Getty Images<p>Finally, and perhaps most importantly, we had started to suspect and now understand that America's colleges and universities are among the many institutions of democracy and civil society that are, by their very design, incapable of being sufficiently responsive to the full spectrum of modern challenges and opportunities they face. Far too many higher education outcomes are determined by a student's family income, and in the context of COVID-19 this means that lower-income students, first-generation students and students of color will be disproportionately afflicted. And without new designs, we can expect postsecondary success for these same students to be as elusive in the new normal, as it was in the <a href="http://pellinstitute.org/indicators/reports_2019.shtml" target="_blank">old normal</a>. This is not just because some universities fail to sufficiently recognize and engage the promise of diversity, this is because few universities have been designed from the outset to effectively serve the unique needs of lower-income students, first-generation students and students of color.</p>
Where can the new normal take us?<p>As colleges and universities face the difficult realities of adapting to COVID-19, they also face an opportunity to rethink their operations and designs in order to respond to social needs with greater agility, adopt technology that enables education to be delivered at scale, and collaborate with each other in order to maintain the dynamism and resilience of the American higher education system.</p> <p>COVID-19 raises questions about the relevance, the quality, and the accessibility of higher education—and these are the same challenges higher education has been grappling with for years. </p> <p>ASU has been able to rapidly adapt to the present circumstances because we have spent nearly two decades not just anticipating but <em>driving</em> innovation in higher education. We have adopted a <a href="https://www.asu.edu/about/charter-mission-and-values" target="_blank">charter</a> that formalizes our definition of success in terms of "who we include and how they succeed" rather than "<a href="https://www.washingtonpost.com/opinions/2019/10/17/forget-varsity-blues-madness-lets-talk-about-students-who-cant-afford-college/" target="_blank">who we exclude</a>." We adopted an entrepreneurial <a href="https://president.asu.edu/read/higher-logic" target="_blank">operating model</a> that moves at the speed of technological and social change. We have launched initiatives such as <a href="https://www.instride.com/how-it-works/" target="_blank">InStride</a>, a platform for delivering continuing education to learners already in the workforce. We developed our own robust technological capabilities in ASU <a href="https://edplus.asu.edu/" target="_blank">EdPlus</a>, a hub for research and development in digital learning that, even before the current crisis, allowed us to serve more than 45,000 fully online students. We have also created partnerships with other forward-thinking institutions in order to mutually strengthen our capabilities for educational accessibility and quality; this includes our role in co-founding the <a href="https://theuia.org/" target="_blank">University Innovation Alliance</a>, a consortium of 11 public research universities that share data and resources to serve students at scale. </p> <p>For ASU, and universities like ASU, the "new normal" of a post-COVID world looks surprisingly like the world we already knew was necessary. Our record breaking summer 2020 <a href="https://asunow.asu.edu/20200519-sun-devil-life-summer-enrollment-sets-asu-record" target="_blank">enrollment</a> speaks to this. What COVID demonstrates is that we were already headed in the right direction and necessitates that we continue forward with new intensity and, we hope, with more partners. In fact, rather than "new normal" we might just say, it's "go time." </p>
Sallie Krawcheck and Bob Kulhan will be talking money, jobs, and how the pandemic will disproportionally affect women's finances.
Scientists uncovered the secrets of what drove some of the world's last remaining woolly mammoths to extinction.
Every summer, children on the Alaskan island of St Paul cool down in Lake Hill, a crater lake in an extinct volcano – unaware of the mysteries that lie beneath.
Manly Bands wanted to improve on mens' wedding bands. Mission accomplished.
- Manly Bands was founded in 2016 to provide better options and customer service in men's wedding bands.
- Unique materials include antler, dinosaur bones, meteorite, tungsten, and whiskey barrels.
- The company donates a portion of profits to charity every month.
These new status behaviours are what one expert calls 'inconspicuous consumption'.