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'Time to Rethink What Healthcare Does, and Doesn't Do,' Says Lown Chief

Analysis  |  By Tinker Ready  
   March 03, 2016

"There really needs to be an alliance among patients, families, and communities. At the end of the day, they get to decide what is the right care," says Vikas Saini, MD, president of the Lown Institute.

Vikas Saini, MD, has worn a lot of hats: philosopher, entrepreneur, cardiologist, and Harvard Medical School lecturer. Today he's president of the Lown Institute, a Boston-based non-profit that seeks to "catalyze a grassroots movement for transforming healthcare systems and improving the health of communities."

Saini recently talked with me about the group's concept of "right care" and how some current approaches to evidence-based medicine fall short. The group was recently awarded a second $2 million grant from the Robert Wood Johnson Foundation.

HLM: The Lown Institute calls for an end to "the epidemic of overuse and underuse in healthcare." Can you talk about the difficulty of getting providers to deliver evidence-based medicine?

Saini: We have a complex system in healthcare. When you have decision making that occurs as fast and as densely as it does in healthcare, using a rules-based approach, in many ways, can slow things down.

One of the issues is that evidence is scarce… The amount of what we do for which there is no evidence is so large, that if you stuck to only the stuff for which there is evidence, a whole bunch of stuff we do in healthcare would simple go away. I don't know if that is right or wrong. The problem is we don't know.

If you took the view that there are a few really central areas that are settled practice and you create algorithms to try to herd the outliers into a narrow corrals, that might make some sense sometimes. But, the reality is that you have to individualize [care] to patients.

HLM: Why won't rules work?

Saini: We have adopted administrative techniques, sort of coercive techniques, for trying to deal with what is a clear problem of practice variation. [The variation] is clearly not justified: the problem is we don't exactly know what the right thing is. In that context, to enforce [guidelines] with either economic disincentives or other penalties, I just think it's part of the malaise.

I think it is challenging for hospital administrators to tell their doctors what to do. They are not doctors and sometimes there are financial incentives in both directions…

They have margins, they have revenues, and to really adopt with a fine-tooth comb an understanding of all the clinical decision—first of all, it's sort of totalitarian; second, it's not going to work. It almost invites hospitals to lose revenue and lose momentum because they spend all this time checking.

In many ways, it's a no-win situation.

Tinker Ready is a contributing writer at HealthLeaders Media.

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