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AHIP: Gawande, Gladwell on Healthcare's Chauffeur Problem

 |  By Margaret@example.com  
   June 25, 2012

The healthcare industry's unwillingness to let go of the so-called "chauffeur model" has prevented commodification and customer autonomy from developing in healthcare delivery, according to Malcolm Gladwell, the noted New Yorker writer and book author.

"That person who stands between the consumer and a (medical) service or technology, and serves as a powerful intermediary, remains in place in healthcare" today just as that person did at the beginning of the healthcare industry, Gladwell asserted Friday at the 2012 conference for America's Health Insurance Plans.


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Not so, countered Harvard professor and author Atul Gawande, MD, who joined Gladwell on stage. "The real problem with the healthcare industry is that it focuses on having great components. We're obsessed with components. We want the best drugs, best tools, and best specialists, but we spend very little time thinking about how everything will work together."

He likened the obsession with the best components to building a car with Porsche brakes, a Ferrari engine, a Volvo body, and a BMW chassis. "Put it all together and what you have is an expensive pile of junk that doesn't go anywhere because the pieces don't work together."

Gladwell presented the chauffeur analogy as an example of what happens when new technology is introduced. At first everyone is unfamiliar with the technology and needs a guide. When automobiles were first introduced they were embraced by the wealthy, but because they didn't know how to drive they hired chauffeurs.

Families needed the chauffeur to bridge the technology. Chauffeurs had power; families couldn't travel in the car without them. But, over time as more people became familiar with cars and learned to drive, chauffeurs lost their power.


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Gladwell pointed to phototcopying as an industry that let go of its chauffeur and grew by leaps and bounds. He explained that when Xerox first introduced its machines in the 1960s a Xerox rep would be on site to take care of the machine. Offices paid a royalty for the number of copies used. "Xerox was the chauffeur." As other companies entered the business and competition increased, the industry changed. The chauffeur became less important.

He noted that two processes that have happened quickly in other industries, commodification and customer control or consumerization, have been slow in coming to healthcare. The reason, said Gladwell, is the healthcare industry has been unable to compromise on the quality continuum.

"A key step in any kind of technological transition is the acceptance of a temporary deficit in performance at the beginning in exchange for something else," said Gladwell. That something else can eventually include increased convenience and lower cost. He offered a number of examples, including the shift to digital cameras where early pictures were not as good as film and the advent of the digital compression of music, which he contends has made the quality of music worse.

The changes in film and music were accepted, he said, in exchange for new opportunities to arrange, manipulate, and personalize our pictures and music. "In healthcare we don't have the same stomach for that period of transition. That's striking to me."

As an example, Gladwell offered dialysis treatment, which was first developed in the 1940s. "In every other technological marketplace there would have been a move to self-administration within the first eight years. That's the trajectory of new innovations in other industries. That hasn't happened in dialysis. The chauffeur is still there."

He noted what he termed "one lonely study" in Sweden where dialysis patients began to self-administer their treatments. Self-administration trimmed costs by 50%, and increased patient engagement and adherence to dialysis regimens.

"After 70 years this is all we have, one study. Why? Because the transition would be difficult."

Gladwell sees some hope in removing the chauffeur in new technologies such as the iPhone, which some researchers think could reduce the number of physician office visits by 70%. "But the transition will still be difficult. There will be a period of time when people will struggle with how to communicate with their provider. Things will go awry."

For his part, Atul Gawande clicked off a number of industries were the chauffeur still exists, such as teaching, firefighting, and police work, and yet progress is made. For Gawande the range of costs in healthcare is key. "We know that the most expensive services don't always yield the best results. If it was just a matter of the highest price providing the best care then we would be having a rationing conversation. We know that facilities that have systematic care environments where treatments and services joined together consistently have the best clinical results."

He contends that penicillin, for all its positive attributes, fooled the healthcare industry and consumers into thinking that there would always be easy fixes. "A simple injection that saved thousands of lives. It made us think that the future of medical innovation was going to be just like that. But it wasn't. Healthcare is intensely complicated. We can't perform our own knee operations. We're all in the position of having to hire intermediaries or chauffeurs."

Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
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