Is Michael Moore a Lean Thinker?

Monday on the Lean Blog Mark Graban did some interesting reflection and analysis on claims by filmmaker Michael Moore that 18,000 people die each year in the U.S. due to the lack of health insurance.
The U.S. population, per Google, is approximately 301,000,000. That gives us 254,000,000 WITH insurance. If you believe the oft-cited Institute of Medicine numbers, 98,000 Americans die each year because of preventable medical mistakes. Also a tragedy. That’s a rate of 0.000386.
Basically the same rates. I was stunned when I did the math in Excel. Is it fair to say that IF you were able to get coverage for those 47,000,000, that just as many (116,000) would die because of medical mistakes instead of today’s total from 1) lack of insurance and 2) medical mistakes?
OK, that’s not exactly right, because the 47,000,000 without insurance DO get treatment, usually through the Emergency Room. That’s not the best treatment always, but we won’t have two exclusive sample sets to compare.
But, I think my overall point is valid — if we’re going to get everybody coverage, we have an obligation to eliminate preventable medical mistakes the same way we’ve pretty much (knock on wood, I fly tomorrow) eliminated preventable airline disasters. Lean methods — process focus, standardized work, root cause problem solving to name a few — can help solve our quality crisis. Our goal needs to be ZERO preventable deaths, absolutely.

Mark Graban is a Lean thinker with considerable expertise in taking Lean concepts to healthcare, helping to make a dent in the number of those preventable deaths in hospitals. But what about Michael Moore? Is he a Lean thinker? Whatever you may think of him as a public figure, he is raising debate on a very important issue.
You could say that Michael Moore is a Lean thinker. Based on James Womack’s latest and simplified definition of Lean as Purpose, process and people (not unlike what we have had pasted on our home page for years) Michael Moore clearly has a purpose (provide healthcare) that is people-focused (make people healthier) and he bemoans the process that insurance industries follow.
Michael Moore had defined an “ideal” or target condition (health insurance coverage for all) and he wants kaizen in this area. He has more compassion and respect for people than some insurance companies do. I haven’t seen the film, but the film maker has is raising awareness of waste in the healthcare system.
There are also arguments that he is not a Lean thinker, and one that comes to mind is that he is presenting a solution (universal healthcare paid for by the government) without a deeper analysis of the current situation and the root causes for where we are today and what is preventing us from having this or something similar.
If these questions were asked, one of the root causes for the current situation comes down to motivating the insurers and the doctors to do the right things. For the insurer it means reduce their costs in other ways than simply denying payment. For doctors it can mean doing kaizen to improve safety, quality and availability of their services.
An interesting article on the Health Affairs Blog by James Robins on on July 10th, 2007 titled Redesigning Care: Jamie Robinson Interviews Virginia Mason CEO Gary Kaplan tackles these issues. One such issue from the interview is:
Why have so few provider groups undertaken the self-analysis that the Virginia Mason Medical Center (VMMC) entered into through its use of the famed Toyota Production System, even before Aetna and large employers began to push VMMC to cut costs?

It sounds as though the work VMMC did with Lean healthcare helped them to make the right decision in working with Aetna:
Kaplan: I think that for our clinical teams it was really a combination of factors. We were fortunate in that we had identified new ways to respond to marketplace issues such as those being presented to us. Rather than defaulting to the usual conventional resistance of many physician groups, including historically our own, by challenging the data or attempting to use market clout or prominence in the community to pressure the insurer, we actually decided to roll up our sleeves, apply our VMPS tools and form a unique partnership with the plan and the employer community.

Dr. Kaplan is clearly a Lean thinker and a Lean leader, who is helping fix healthcare from the inside:
As part of our VMPS work we consider the entire “value stream” from the perspective of our patients, our customers. We consider how the patient enters the care-delivery system with a particular diagnosis, and the components of the value stream that may or may not be value-added. What we found in our work, as is described in the Health Affairs article, is that for many diagnoses, the value stream has included a lot of waste — a lot of non-value-added diagnostics and therapeutics.
One of the biggest root causes of waste in any process or any industry is wrong behavior (not doing the right thing) because of wrong measurements and incentives. Dr. Kaplan’s response to Robinson’s question regarding changing payment models is enlightening:
The current fee-for-service payment system and the current way of valuing services needs to change if value-based care delivery is to be embraced by physicians and hospitals across the U.S. Most conventional pay-for-performance, as I think about it, is going to pay incrementally a relatively small amount for doing the right thing, as opposed to incentivizing us to not do the wrong thing — not to do the things that are a tremendous amount of waste in the system — and I think that’s where the big savings in care and the biggest opportunity lies.

Another potential root cause for out of control costs is identified in this exchange:
Robinson: America has been on a drunken fee-for-service binge over the past five years, and now we are seeing what you get from incentives to do more and more and more…
Kaplan: …And there is the added impetus to cost escalation of new technology and the ever-increasing expectations of our patients.

And yet another very insightful comment from Kaplan:
I think much of our training, socialization — you used the term guild system — the liability climate, expectations of patients and other factors have spawned the feeling amongst physicians that autonomy is critical. This is an issue that works against continuous improvement and collaborative work. At times this has fed the notion that one’s personal economic interest was paramount and this is certainly not what American medicine should be about.

On the role of cross-functional kaizen teams in motivating change from the inside, Dr. Kaplan says:
One of the things that characterize our project, which is described in the Health Affairs article, is unprecedented collaboration with employers including having their representatives from top management — human resources and employee benefits — involved on our Kaizen teams and very much at the table in this work. That was a very powerful influence and helped our physicians and care delivery teams enormously.

And this is a great question by Robinson, with a great answer by Dr. Kaplan:
How do you compensate your physicians internally to support and sustain a culture of efficiency improvement?
Kaplan: First of all, we select people in our recruitment process who are interested in improvement and making a contribution to their specialty and to the improvement of care delivery. We have a strong ethic around teamwork, academics and improvement. We have incentives, both time and money. People get credit for a variety of improvement activities; committee work that allows that to happen; and participation on VMPS rapid process improvement workshops and in workgroups such as the Kaizen teams that focus on low-back pain, migraine, and cardiovascular work. We work hard to ensure that we are not disincentivizing things that we as an organization highly value.

The whole interview is worth reading for anyone interested in Lean. There are nuggets there that you can generalize and apply to the challenges of Lean in any organization.
For further reading about VMMC and their efforts, Health Affairs has an article titled Redesigning Care Delivery In Response To A High-Performance Network: The Virginia Mason Medical Center.
At the risk of sounding like a proponent of socialized medicine (which if it is a solution is not one that addresses root causes of the problems identified above) I do think that the health of a nation is the business of government.
Insurance companies, hospitals, public health policy, disease control, all of these things are part of what you might call the “public health value stream” that should be owned by the public sector, or government. We can’t consider just the hospital or just the insurance company, but rather the full so-called “product life cycle” of healthcare delivery (ironically, this is exactly and actually the “life cycle” of a human being).
Without a broad perspective and long-term vision, all parts of the healthcare delivery life cycle will continue to sub-optimize, raise overall costs, and erode quality. Pharmaceutical companies, insurance companies, doctors, providers of unhealthy food and lifestyle elements, and even consumers who choose to live unhealthy lifestyles are all contributing to sub-optimization and waste. It’s a big enough problem that we need help from everyone, and from all of the Lean thinkers in healthcare, regardless of politics and regardless of whether they make movies, write blogs, or run medical centers.

5 Comments

  1. Mark Graban

    July 12, 2007 - 7:08 am

    I just read the Kaplan interview this morning over coffee and haven’t been able to blog about it yet (and maybe now I don’t have to).
    The whole “fee for service” approach that healthcare traditionally has amounts to “piecework.” You get paid for stuff you do, rather than the results you get.
    Virginia Mason was trying to “do the right thing” in terms of reducing “overprocessing” and not doing expensive tests when cheaper tests would do. That’s good for the patients and the insurers, but guess what? It’s BAD for Virginia Mason because they get less revenue. That’s very broken. They referred to it as a “100% tax on kaizen” in the interview. You make improvements, you lose. Not good.
    The interview also points out how Medicare pays more, sometimes, to the least efficient, high cost hospitals. Again, that’s the wrong incentive, we subsidize waste and inefficiency.
    Payers (government and otherwise) are moving toward paying set amounts based on certain diagnosis codes. But how are those payments set? Is that a fair system just because some Harvard researchers (literally) determined what the payments would be. The “payment for code” creates different incentives to “fudge the codes” in a number of ways. Also broken.
    I don’t know what the answers are. I’m still working on understanding the problems! But, improving flow and eliminating waste can’t be bad things to do… I hope!

  2. Matt

    July 12, 2007 - 7:24 am

    This is a personal interest of mine, although I have no first-hand experience. I just read a lot about it.
    I emailed Mark Graban about this as well, but since you’re in the Seattle area, you might know more about this. According to the Seattle PI
    http://seattlepi.nwsource.com/local/323227_virginiamason11.html
    Virginia Mason is losing money. Now, they’re doing the right thing, but, from a business perspective, this looks like doing the right thing will cost money.
    Also, I think Dr. Burney has a few good points against single-payer healthcare systems. Mostly, its the opinion that competition is the only thing that will motivate efficiency.
    http://www4.asq.org/blogs/healthcare/2007/07/healthcare_for_the_needy.html
    On the surface, these points seem contradictory. So, from a lean perspective, what do you think?

  3. Mark Graban

    July 12, 2007 - 6:41 pm

    Actually, I didn’t read that as VM losing money altogether:
    “Virginia Mason Medical Center’s efforts to increase efficiency and reduce patient costs proved a money-losing experiment that others may hesitate to pursue, a study finds.”
    This experiment in reducing overprocessing has cost them money.
    Their 2005 annual report shows a 1.4% “profit margin” (they’re in the black, but not by much).
    I’m pretty sure the average profit margin for a hospital is only 3 to 5%. They’re not floundering, but not doing great, as far as hospital margins go.
    You’d have to hope that Lean would help margins by cutting costs (through improving quality and reducing waste) to make up for the loss from getting rid of the “overprocessing.”
    Again, a problem with the pay-for-service model.

  4. Mark Graban

    July 12, 2007 - 6:53 pm

    Not to be too negative, but the “competition” in the U.S. system hasn’t driven that much efficiency. Innovation and new drugs/technologies maybe, but not perfect efficiency. The UK system (and others) struggle with the same types of waste, to about the same level. Canada has a similar per-capita rate of deaths due to medical error as the U.S.

  5. Anonymous

    December 7, 2007 - 12:09 pm

    LOL