Courtesy Kevin Drum, a Wall Street Journal piece on Devi Shetty, an Indian surgeon-entrepreneur who has adopted a more-is-better approach to heart surgery, and in doing so driven prices down while improving outcomes:
Dr. Shetty, who entered the limelight in the early 1990s as Mother Teresa’s cardiac surgeon, offers cutting-edge medical care in India at a fraction of what it costs elsewhere in the world. His flagship heart hospital charges $2,000, on average, for open-heart surgery, compared with hospitals in the U.S. that are paid between $20,000 and $100,000, depending on the complexity of the surgery.
The approach has transformed health care in India through a simple premise that works in other industries: economies of scale. By driving huge volumes, even of procedures as sophisticated, delicate and dangerous as heart surgery, Dr. Shetty has managed to drive down the cost of health care in his nation of one billion.
A large fraction of that difference is the lower salaries paid in India, and the uniquely inefficient mess that is the US health system. But, even compared with other Indian clinics, the costs appear to be in the order of 50% lower.
The importance of “critical mass” in achieving good surgical outcomes was noted in the context of the Mersey hospital debacle. Another tidbit I’m familiar with is that specialist gastroenterologists detect a higher proportion of abnormalities when performing colonoscopies than non-specialists do. So it doesn’t surprise me in the least that treating lots of patients seems to work well both financially and in terms of outcomes.
Surgery, and what goes on in hospitals more generally , is not the be-all and end-all of health care. But I’d be surprised if there aren’t some areas of the Australian health system where further rationalization and specialization would produce better outcomes, more cheaply.
You and your silly notions about the division of labour improving productivity. Next you’ll be trying to flog silly notions about gains from free trade.
Not quite, Jacques—he’s reducing costs through elimination of waste and getting standardised work practices out of his surgeons. Unless it’s actually surgeons reducing the scope of the tasks they’re doing it’s Taylorisation aka scientific management, not division of labour.
Liam, it’s division of labour in that I gather you get surgical teams who specialize in doing only one sort of operation.
Yes, there’s also a fair bit of waste elimination, and standardised work practices, and screwing suppliers.
The screwing suppliers is something Australia does fairly well in the PBS. I’m not sure we do nearly as good a job of screwing over the manufacturers of sutures, scanning machines, and so on.
And the major stumbling block… the AMA!
“But I’d be surprised if there aren’t some areas of the Australian health system where further rationalization and specialization would produce better outcomes, more cheaply.”
Hang on. I’m not quite sure how this would square with the high price of public school fees, luxury car repayments and holiday house maintenance. For more information see ‘cataract fees’ and how, once set, they never recede, regardless of how many operations you can whiz through in a day, before golf in the afternoon.
Production-line surgery sounds a bit like Henry Ford’s factory process- surgeons lined up and doing just one thing before the patient moves on to the next in line, then finally,after the last stitch, they are wheeled off to the recovery ward.
I recently had cataract surgery at a Sydney day clinic. It was certainly production line. On each occasion the anaesthetist, surgeon, and theatre and recovery room teams had a list of seven or eight patients lined up one after another in the one morning. On the morning following we all showed up again one after another to have the dressing taken off and our eye checked. As far as I could tell these people do not do bowel, lung, urino-genital or spine surgery, but confine themselves to eyes.
I would have been concerned if that was not the case.
Is someone trying to use “production line” as a scare term to somehow imply that Chetty’s hospital or indeed the people who operated on my eyes are somehow less qualified or give a lower standard of service than whatever hospitals do that are not organised on a production line?
Production line surgery is not the same as production line manufacture of meat pies or Holden cars, in that each patient is different. In the case of the eyes, we were each individually examined some weeks beforehand, complete with tests of eye function and structure. Despite the production line setup I had no sense that we were being treated anything other than as individuals.
A couple of years ago I had a colonoscopy and again it was a production line deal: the surgeon lines up a string of patients on Mondays and Fridays, peers up their bums one after another and scrapes, burns or slices off anything inside that shouldn’t be there. Although I didn’t think to ask, I’m sure he doesn’t do eye surgery as well.
I have no doubt that there is room for further streamlining behind the scenes for both these procedures in a facility that does dozens, perhaps hundreds a day. There is also scope for far more application of statistical quality control and research of continuous improvement initiatives.
The issue that joe2 alludes to is that the government is saying that with current techniques and equipment, cataract surgery is a far quicker operation than it used to be, and is threatening to reduce the Medicare payment for the procedure from around $700 to $350 (from memory). Cost of the clinic is on top of that (taxpayer funded if in a public hospital, around $1400 if a private facility).
What Patrick Cooke used to call the Painters and Doctors Union is of course bitterly resisting the reduction.
I have just received a thing from the Fred Hollows Foundation asking for donations that says they aim to perform 12,000 operations a month and that they do them for $25 apiece.
Go figure.
A couple of years ago I was admitted into a “production-line” style hospital for some fairly minor kidney surgery.
Those m()therfuckers turned me into a Ford Taurus.
Now I have a pretty hard time getting up staircases and I have to sleep in a parking garage, but OTOH I have to say my gas mileage isn’t that bad, and the cup-holder comes in pretty handy.
But it really hurts to be keyed, let me tell you.
I’m using “production line” in the sense that they churn out lots of manufactured goods very cheaply and of far higher quality and consistency than craftspeople typically achieve.
Part of the problem is the convoluted way we train someone to do standard surgery procedures. For example, the eye surgeon doing the cataract operation will have spent years training to be a GP and had to learn things like the anatomy of the foot along the way. From a surgeon’s point of view this is good because all those wasted years of training justify the big fee. My understanding of the Fred Hollows system is that they take about three months to train someone to do cataract surgery.
If someone is operating on my eyes I want to be sure that they can do the job properly, not that they know a lot about my foot. If someone is going to be doing something potentially difficult on my eye I also want to be sure that they have what it takes to deal with problems as they arise.
Roxon’s challenge is to convince medical researchers that finding lower cost ways of fixing medical problems makes just as big a contribution to world health as developing that sexy new procedure that only the rich can afford.
No.
They will have done a shitload of extra training on top of basic medical degree to do eyes. Even with basic medial training you don’t just walk out and put up a shingle and become a GP.
A GP is not a lesser trained being. To be a GP you do extra training and learning. A brain surgeon can’t walk out and become a GP. And thank god, a bloody Ortho-pod can’t walk out and become a GP. For that we all give thanks.
Yes you can do cataracts in Africa at $25 a pop, in a tent with a bunch of cowboy volunteer ophthalmologists and trainees. But it isn’t safe. The risk is worth it if it’s a choice between blindness and sight. And no other opportunities in your lifetime.
With a 3% or more chance of a serious fuckup due to non sterile conditions and things going wrong. If things go wrong with a “simple” cataract op (and they do even in big teaching hospitals at about 1.5%) then you need big time quick backup with serious skills and other facilities.
Thats why we don’t have cataract clinics in suburban shopping centres. Thats why we don’t even have them very far from major hospitals.
Yes you can do cataracts with production line efficiency and bang out 8 or 12 a session. But almost no one wants to do cataracts only 8 sessions a week. It’s hard highly skilled boring work.
You could/can train up technicians to do cataracts – but then you need to have them almost exclusively in large hospitals right next to (literally) highly skilled ophthalmologist with high tech equipment. Minutes and sterile conditions matter.
I just looked at the original post by Merkel.
In UK and some other places they have special technician colonoscopists (I think they are all nurses) and their success and safety (very important with bottom scopes) are very good. I think Germany uses technicians too – in general EU is more up with using technicians. Some are so good they don’t use any anestheasia.
The trouble is not everyone wants to do colonoscopies all day every day – even if doing tops scopes as well. And there are limits to efficiencies – with colonoscopies the standard is that a withdrawal of less then 8 – 9 minutes is not high enough quality for detections. So there is an absolute limit of efficiencies.Probably 20 minutes a bottom scope.
Other than thats – yes most good surgery that isn’t “heroic” front page current affair Oprah stuff is best done by high volume protocol driven practitioners and clinics.
Getting a colonoscopy done? – you need to ask – how many do they do a year /week? What is the perforation rate? and do they take a minimum of 8 minutes to withdraws? if they can’t answer go elsewhere. A lot of good operators actually send out these figures to GPs.
And you don’t have to be a gastroenterologist to do scopes – any general surgeon can.
Don’t go to some country GP who will get you in quicker but only does a 100 or so a year.
robert I just looked at that USA study on colonoscopies you linked to.
I’d like to invoke my standard response to most things – “I think you’ll find its a bit more complicated than that”
The study claims that colonoscopies are more effective in detection (I don’t think it mention safety – and don’t forget you can die from a simple perforation) if performed by gastroenterologists compared to general physicians (GPs).
But – the real difference will, I think, be volume and large hospital access NOT type of person performing.
That is Gastros doing low volumes in their rooms separate from hospitals would probably have worse rates than a physician doing large volumes in a large hospital.
Spin from Gastros I’d say.
You might also be interested to know that USA (and sadly Australia) does about 4 times the colonoscopies than does UK.
BUT bowel cancer detection/ outcomes/ deaths rates are essentially not different.
The difference is that UK insists, for most purposes, that a low cost home Feceal Occult Blood Test (FOBT – get one from your GP/chemist) be done and a positive before colonoscopy is performed.
Colonoscopies are expensive – probably around $900 and there are waiting lists – thats billions of dollars.
Part of the difference is that you don’t need a GP referral to go to a specialist in USA
FXH: “That’s why we don’t have cataract clinics in suburban shopping centres”…
Frank, that’s just not true. I know because over the last few months I’ve been doing the multiple trips involved in having the good medical staff of XXXX Eye Hospital, (situated bang in the middle of the Redcliffe retail shopping strip, and if that ain’t suburban I don’t know what is) getting my Mum’s peepers peeping properly again. They don’t do both eyes at once, y’see, and there is a follow up protocol.
The multiple late model beemers with personalised number plates, (texts of which are perilously close to advertising), in the clinic car park, and the unlikeliehood of a punter finding a park there, suggest there’s more than 8 or ten sessions a week going on inside.
Maybe I’ve been going to the only cataract clinic in a suburban shopping centre in this wide brown land of girtbysea, it’s an anomoly, and Frank’s factoid is otherwise accurate, but I’d be surprised.
Given the acute and deep affection procedural medicos have for the sport of shooting big billing opportunity fish in multiple tiny barrels, such as the gerentocracy-filled suburbs represent, the chance that several corporate medicine franchise models designed to capture the latent value there, up to and including offering reverse mortage finance options, aren’t being vigorously marketted, is slimmer than tpg’s tax exposure.
For instance: the cardiologists were well ahead of the curve in having a joint venture corporate model ready whereby they band together to take equity in radiology practices – which they then they can all (over?)refer to-, and thus use the new CT heart scan medicare billing item to deliver very nicely indeed to their joint ventures’ bottom line. They were all set up for business before the item was even on the medicare schedule. Painters and Doctors indeed.
danny – turn of phrase. There are cataract clinics in places other than hospitals but they aren’t in the back room of a GP surgery. And higher risk people are filtered out.
Theres some good reasons they don’t do both eyes at once. One reason is that if it goes wrong then there is the other eye left to hope for.
I wasn’t defending private ophthalmologists fees for cataracts.
But this current kerfuffle is a stupid political one – badly handled by federal bureaucrats. As a matter of tactics you don’t just cut the fee in half with a sudden death un-telegraphed move – you reduce it over time.
After all people have made legitimate plans for new buildings, clinics staffing etc based on current rates. To blow that out of the water without notice is wrong. You give notice – about 3 years ago – that efficiencies mean the old fee is looking too high then reduce it down to about half over 3 years.
Sure theres a bit of whinging by the AMA you expect that but it works. AND you would have saved money on the 30% reductions over the last 3 years.
Expect more dopey implementation decisions form the Feds as they take over health in the next 10 years. Remember Godwin Greches are all over Canberra public services. He was a Lib but others are Lab, Green, and just plain wilful.