Tensions Creating Less is More; Quality and Quantity

Per my last post, I just spent a week getting fired up about Integrative Thinking, thanks to the CMA and the Rotman School of Management.

The "Right Care" or "Appropriateness in Medicine" or "Less is More Medicine" movement – whatever you want to call it – is a synthesis of the tensions in the healthcare system that exist between the system's needs and the patients' needs. There are common goals, and even tensions between those, eg. between high quality care and a minimally disruptive process, between an efficient system and comprehensive services, between sustainability and quality, and between patient empowerment and provider accountability.

It is possible to have the "best of both worlds," but it is going to take a lot of work to figure out how to get there. Less is More begins by challenging the assumption that "More is Better." By accepting that quality and quantity are not inextricably linked, we open up a world of possibilities for the future of healthcare in Canada. Unsurprisingly, quality and quantity are often at odds for patients who are in their final years, which means that the "less is more" approach often naturally arises in end-of-life care.

In math class as a a kid, I always liked to solve a problem and then do the problem in reverse, to make sure my answer was right. Thinking about "appropriateness in medicine" I realized that maybe we already do have the solution. If I work backwards, will it ensure it's the 'right answer'? Or at least, one possible solution? Can we integrate High Quantity Care with Low Quantity Care to create the Right CareCan quality and quantity be reconciled for something in between, like the "just right bowl" of porridge that Goldilocks found?

The current, unsustainable and ineffective state of healthcare is in part due to the pathological thinking that arises from funding quantity rather than quality of care. By incentivizing disease rather than health care, it's no wonder cost are soaring and health outcomes are slipping. However, it is exceedingly difficult to measure quality, as we've yet to agree on a definition. One idea are QALYs, Quality-Adjusted Life Years, but this measure is not without issue.

If we pick the wrong measure, "payment for performance" models could also lead us astray. This year, we've learned that high patient satisfaction is correlated with increased morbidity and mortality. So, even though institutions and careers were made with this measure, giving patients what they want is not actually in the interest of their health!


There are many options:

-  Performance Measures: find useful quality measures, and create methods for measuring physician/nurse/system/etc. performance; make it auditable, provide feedback, unlicense those whose practices deviate significantly. This is scary for doctors because it diminishes our autonomy, something we value greatly, but it could lead to better access, quality, and efficacy. It may be quite a challenge since patients are ultimately responsible for their health. No matter what a nurse or physician does, there is a lot of the patient's health that is beyond the healthcare provider's control. As well it should be, since we ought to be shifting away from paternalism to patient-centred care, where people take ownership for their health and partner with experts who can guide them along the way.

- Bundled payments: where providers get a lump sum for the handling of one process (eg. hip replacement: it would include pre-, intra- and post-operative recovery including management of complications). Given a lump sum, the team would be motivated to provide the best care, which likely entails shorter stay, fewer medications, better quality surgery, best outcomes, etc. If they manage to save a lot of money by making the care efficient and effective, they profit. If they do a bad job, it costs the providers - not the system. This model provides a disincentive for unnecessary care, but doesn't allow for a lot of self-direction. Special consideration would be needed to account for more challenging patient populations.

- One price per patient per year: no matter how well or sick the individual, the system would have a fixed amount to care for them. This encourages providers to emphasize and support preventative health measures, and to use tests/treatments judiciously. For example, a practice would probably elect to follow Evidence-Based practices that show high value and efficacy. For example, doing colon cancer screening (a small cost) will allow detection and treatment of colon cancer at a time where it would be cost-efficient as well as in the best interests of the patient to intervene; if you don't screen, you find the colon cancer later and it is harder and more expensive to treat. Difficulties? It would take a long time to bear out successes. Also, the sickest patients might never find physicians. Also, physicians may have a hard time combating the consumer culture of "more is better" and thus be unable to provide efficient care.

- ?? More

I have a lot more reading and thinking and integrating to do. The next steps for me involve seeking out more opposing points of view, and to find those, I just have to talk to more and more people about these ideas and hope that I find lots of conflict and disagreement.