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

"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.

HLM: Do programs like the ABIM Foundation's Choosing Wisely campaign get at the problems of "over-use" and "under-use"?

Saini: Choosing Wisely is low-hanging fruit. I would be hard-pressed to say there is much ambiguity there. I've never seen an estimate of how much money would be saved if you got rid of all Choosing Wisely activity in the American healthcare system. I would be surprised if it saved a lot of money.

Part of the real contribution of the Choosing Wisely initiative is in flagging the idea that there is stuff that just shouldn't be done. Making that statement is a huge ice breaker. For those of us who have known this and said this for 30 or 40 years, it wasn't shocking, but it was great that official, organized medicine was willing to say it. In that sense is was really important.

A lot of what happens in healthcare is in a gray zone. Care needs to be individualized; it needs to be sensitive to patient preferences. My own view is that the default option should be the less invasive, potentially less harmful option, and the less expensive option if there is no clear proof of superiority. So, yes, Choosing Wisely is great as a start, but it gets hard after that.

HLM:Can you talk about the concept of "right care"?

Saini: What right care really means is care that is effective—scientifically based—and which is sensitive to the patient preferences; it is wanted. Those preferences need to genuinely be elicited; that requires a strong relationship.

You can do a checklist and it sort of works. You can have shared-decision aids. That definitely helps, at least in trials of shared decision-making. [The question is whether they will work in deployed outside the clinical trial setting.]

The other element includes a dimension of economic stewardship. It's not that the provider or healthcare system need to be the stewards. There really needs to be an alliance with patients, families, and communities. At the end of the day, they get to decide what is the right care.

That is, not when an individual gets sick. Any of us, when we get sick, we want everything. We want the best. The problem is defining what that means at a population level. It's never easy. Our conception of right care is that there will be a day when patients, families, and communities think about this as citizens, as opposed to in the moment of the illness. That is the only way we'll get to the answer to that question. It can't be answered by experts. It can't be answered by technocrats. And it can't really be answered by patients.

There is a level of of deliberation that is not about individual care. It is a public deliberation about the nature of healthcare and what we want. How much do we want to spend and what for? When there is decreasing return, would you want to spend it on this or that? It's not about rationing. it's about figuring out what everyone's values are.

I think if you ask 95-year-old patients would they like to spend $500,000 in the last two months of their lives or would they rather leave $500,000 to their grandkids, it would be an interesting conversation.

HLM: Do you think initiatives associated with the Patient Protection and Affordable Care Act will move us closer to "right care"?

Saini: There are some new, great initiatives. It's a lumbering first step, so I'm not going to denounce it. I think it is a step forward, but I think that there are a lot of landmines, certainly with regard to value and in the area of overuse or unnecessary care.

I'm a veteran of the late '90s when it wasn't just managed care by the insurance companies: 1-800-no-you-can't. It was also clinician networks taking financial risks, what we now call ACOs. Rethinking how they are doing things, referral pattern changes. That's not new; that was 20 years ago.

What happed was politics—pushback from other stakeholders in the system. We got another bout of medical inflation, and now, we're poised once more to step forward.

But I would say the jury is out. There are many ways it could be turned back. One of my concerns is that there is a Faustian bargain. We've offered a lot of affordable plans—high co-pay, high-deductible plans—that give people so-called 'skin-in-the-game. And yet the information asymmetry and the power asymmetry is so vast, that it is really not realistic to expect a consumer-type relationship that will drive utilization…

I think if you give people high-deductible, high co-pay plans, they continue to face financial pressure. Some of the costs are moderating, but it is still too damn expensive relative to [people of] median income in the country. I think that's a huge political landmine because at some point, people are going to start asking, 'What is going on here?' We're seeing it with the drug prices.

HLM:What needs to be done?

Saini: I get that it sound Pollyanna-ish, but we think it is time for a new reformation in healthcare, in the provider community and beyond to rethink what it is that healthcare does, and what it doesn't it do.

Tackling these issue requires a change in mindset, a change in attitude, a change in framing, and almost the creation of a new way of thinking about what we do. That's a big job. It's clearly very complex.

Doctors, nurses and other healthcare providers need to work with civic leaders and community leaders, and share both their experiences and what they know and together craft a program that represents a path to a reformed healthcare system. I don't think that is what happened here. I don't think the ACA represents any public input.

We're building this network which we are calling the Right Care Alliance. It is recruiting mostly peer-to peer around specialties and areas of interests. It's just getting started. Our idea is that, over time, as it grows, we reach a critical mass and we'll have local networks. In any individual area, We'll have community members who can support each other and can begin to craft a counter-narrative and take that to the public.

We intend to craft a new community that is really change-oriented, that has the technical understanding that doctors and nurses can bring, but also the real world concerns of community leaders and small business leaders about the interaction and intersection of costs and quality