Lean Thoughts on "Sicko"


I've been asked a few times by blog readers about the movie “Sicko” since I work in the healthcare world. It opens tomorrow in the U.S. I haven't paid for a Michael Moore movie since “Roger and Me,” a movie that did have quite an impact (a brainwashing impact that leads to kneejerk “GM bad!” reactions, some would say) as a Detroit-area kid whose mom is from Flint and someone with personal and family history with the auto industry.

I'm going to write about what I expect to see and how I expect to react. We'll see how the movie stacks up in reality. I have read plenty of reviews (over a dozen) and have watched Michael Moore interviews on Youtube. No, I didn't download the movie online, but that was more due to lack of good broadband connections than lack of nerve, will, or technical skill. The trailer can be found here on Youtube. I'm trying to avoid kneejerk “Michael Moore bad!” reactions, as well here, trying to come into this with an open mind. I'd invite others to do the same.

One thing that was powerfully reinforced to me during the Global Lean Healthcare Summit that I just attended is that we have to separate our world's healthcare problems into a few categories:

  • Problems with access to care
  • Problems with delivery of care

“Sicko” appears to focus solely on the first problem. The Hollywood Reporter review says:

“Sicko” posits an uncontroversial, if not incontrovertible, proposition: The health care system in the U.S. is sick.”

Yes, but sick in what way (or ways?). I think Dr. Moore has only diagnosed part of the problem (good news, he thinks he's curing you of TB, but he missed the pancreatic cancer that's also brewing inside you).

As the NY Times review said:

“I haven't heard many speeches lately boasting about how well our health care system works.”

The first problem, the lack of access to care – and Moore focuses less on the uninsured than on those with insurance who get systemically screwed by the insurers and HMO's. Moore than beats the audience over the head with his simplistic view that socialized, government-run systems are better (and practically Utopian).

From what I've read, “Sicko” largely ignores (or completely ignores) the problem of waiting times for people who DO, in theory, have coverage in socialized medicine countries like Canada and the U.K. You have coverage and can get routine or elective care, but the waiting times might still be outrageous. Is waiting two years for a hip replacement surgery any better for your quality of life (when you're 85) than NOT being able to get the surgery. The definition of “coverage” seems to be a very loose one, at best. At the summit, I heard the story of an attendee's elderly parent, “covered” under “universal care” who was not able to get a hip replacement. The parent had practically never been sick, paying in, but not dipping into the system. And they couldn't get care when they finally needed it (and were desperate to improve the quality of their remaining life).

This ign.com review puts it well from a British perspective:

But Moore neglects to ask how long we need to wait for a hospital bed in many cases. Or if people ever get sick because the hospitals they're staying in aren't clean enough. This is where our NHS fails, but because it doesn't support Moore's case it's simply not mentioned.

If you look at the “just in time” principle of Lean and the Toyota Production System, you might say that products (or healthcare) should ideally be delivered at the “right place, right quantity, and right time.” It seems that the socialized medicine systems don't always meet the “just in time” criteria either. “Free” access isn't free to everybody – it must be paid for. And since no country has infinite funds (with maybe the exception of the U.A.E.), rationing or delays must inevitably occur. Don't count me in with those who think a profit motive or free-market is inherently evil. However, as Moore shows in “Sicko,” insurance bureaucrats who deny claims to covered individuals as a way to pad corporate profits might be the closest thing to evil we might find in the film. Here we have a case of patients WITH coverage being DENIED care. Our system isn't perfect, but neither is socialized medicine. We're human, therefore we design imperfect systems, regardless of how well intended we might be.

From the Hollywood Reporter:

The tales unravel about how a successful medical claim is called a “medical loss” by the insurance industry and how denying claims can lead to promotions in that industry.

The “value” provided to the customer is a “loss” to the managed care provider. Is insurance about the only industry where this is true? Apple does not make money by denying iPhones to customers who want them. Insurance companies, however, pit themselves against us – we “win” (get care), they “lose” (lose profits).

So let's say we've “solved” the access problem with socialized medicine… well except for the waiting. We would still have massive patient safety issues and unnecessary (or at least expedited) patient mortality. As many have come to say, “hospitals are a dangerous place.” Giving more people more access to more care will increase their exposure to errors, potential harm, and expedited death. Again, access to imperfect care is probably better than NO access to care in most cases.

I'm not here to solve the problem of the insurance system. Plenty of others are debating and discussing that. Giving universal coverage to all almost seems like an unfixable problem. But, we CAN fix medical mistakes (and I'd recommend a more informative and less political documentary, such as “Good News… How Hospitals Heal Themselves.”

Every country around the world (at least the 20 countries represented at the summit) has care delivery issues – errors, medical mistakes, and a lack of standard treatment protocols (or failure to follow them) is hurting and killing patients:

  • ED's are overwhelmed, slowing treatment and care (sometimes tragically so)
  • Radiation therapy machines malfunction, giving a lethal dose to a patient
  • Wrong drugs are given, causing death
  • Wrong site surgeries occur due to lack of error proofing and lack of “time outs” to confirm the right procedure is starting
  • Lab specimens or results are mixed up, giving mistaken diagnoses which delay treatment (or cause harm)
  • Hospital acquired infections are spread at rates much higher than hospitals with “best practices” in prevention

I could go on. My point is to look out for this: we should feel a moral imperative to increase BOTH the access to care AND the quality of the care that's delivered. It continues to amaze me that the numbers of uninsured Americans (almost 50 million) gets thrown around much more regularly than the numbers of Americans killed (100,000) or injured by hospitals and our poor processes/systems.

As Moore was quoted in the Time review:

“”We are the richest country in the world. We spend more on health care than any other country. Yet we have the worst health care in the Western world. Come on. We can do better than this.””

Yes, we can do better. But I'd argue it's easier to focus on the estimated 30% of healthcare spending that goes to waste instead of the roughly 30% that goes to administrative overhead. I agree we can do better – but let's focus on continuous process improvement and kaizen instead of just tinkering with the payment system.

“Sicko” seems to be less of an indictment of healthcare delivery system and more of an indictment of the American system of insurance. Regardless of your thoughts on a single-payer system (I'm currently against it), I'd hope we could all agree on a moral mission to dramatically improve the quality of care delivery. Lives are at stake in both cases.

Updated: Here's a piece from today's WSJ about problems in Canadian and UK health systems, how they're considering market reforms. The grass is always greener…

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. I like your argument that there are really two problems with health care: access and quality of care. As a sole proprietor the first issue hits close to home. My husband has a job with good health insurance – it’s the only way I can afford to do the work I do.

    Eliminating hospital waste under the current system may improve the quality of care but does not solve the problem of access to care. If a hospital spends 30% less, a good chunk of that money is going to flow to insurers (if not hospital investors) as profit rather than provide care to more people. Ditto for eliminating waste at insurance companies inside the current paradigm of health insurance.

    To solve the access problem, we need kaikaku here, not kaizen.

  2. Some of my thoughts:

    1) health care is an extremely important, costly and complex area. Given the difficulty even Toyota has after decades of applying their ideas to producing cars it is no surprise there is tons of room to criticize any country’s health care systems – they all need a lot of improvement.

    2) Thankfully you, IHI, Management Wisdom, St Mary’s, Theadacare, LEI, Group Health Cooperative… are making great efforts. There is still plenty of room for way more to join all of you.

    3) If you want to learn about the health care system take the points out of the context of Roger Moore. As I posted yesterday, I find many people ignore the content and just focus on the messenger to determine how they will respond). Even more true with polarizing figures (on the big national stage or within an organization). If you find the content of Sicko invalid even if it were spoken by someone you are biased toward (say James Womack – for lean blog readers) – fine.

    4) A study I ran across this week shows the USA well down the wait time list (of countries). Interesting given the almost universal first objection (to the fact that the USA spends far more than any other country on health care and has far from number one outcome measures) is that all those other countries take away your freedom – you will be waiting for some bureaucrat to ok your medical treatment not like here where we can get treatment whenever we want. Argh: I can’t find it now – I will see if I can find it and post a follow up. My guess is everywhere has a problem allocating resources – health care costs a lot of money.

    5) We need to improve the system. Applying lean thinking is a great way to do this.

  3. Mark & I grew up on the west side of Detroit, but my brother works for a non-profit hospital system over on the east side. Despite the title “non-profit,” he points out over and over again that the nuns can only give away so much money. If the system doesn’t continually bring in 2-3% margins each year, there won’t be enough money to keep the buildings standing.
    Economics, the science of scarcity, teaches us that the two problems of access to care and delivery of care will always be with us under any scheme.
    Lean teaches us how to optimize systems, end to end to get the best quality to the most people at the lowest cost.
    It’d be nice if more could work like Mark and my brother, in the trenches apply lean to healthcare…then we won’t have to keep listening to folks like Michael Moore.

  4. Firstly, I dont think that Socialised medicine hospitals are any dirty than those that are privately run. The clear difference is that within a socialised medicine system that data is made available to all. See the Health Care Commisions website for info on the UK. I am not sure that hospitals in the US or privately in the UK are quite so ready to publish that information.

    As to wait times. I completely accept the failings of the systems both public and private. I also accept that in a private system where treatment is approved, access is almost certainly faster.

    However for those in a private system with coverage but denied access they are worse off than any wait in a socialised system.

    I was with two orthopods yesterday afternoon working on fractured neck of femurs and we were discussing a 83 year old lady suffering from dementia who had fallen and the operation they had done. How does that improve her quality of life? They are not necessarily happy about having to provide care because it means some people will get treated inappropriately.

    Waiting times. By November 2008 no patient in the UK will wait more than 18 weeks from referral to treatment (at least thats the plan).

    At present the data indicates less than 50% wait more than 18 weeks.

    Suspected cancer patients wait no more than 2 weeks, the majority will wait hours or a couple of days. The longest wait is 14 days.

    In the UK same day mammography scanning, reporting and referral to treatment was pioneered. I was in a large world class US teaching hospital last October and they have only been achieving this within the last year, the UK has been doing this in some places for more than a decade.

    I agree with Mark that there are 2 problems and that they are access and quality.

    Having experienced both systems, the quality is pretty poor in both, the conference we were at has simply reinforced that belief.

    Speed of access for those with coverage is probably on balance faster in the US, but access for the majority has to better in Canada, the UK and NZ and OZ where it is not dependent on ones ability to pay.


  5. Mark, as usual, you nailed it. And Katherine’s comment of needing kaikaku is right on the money. Here’s the open question – how can we bring the key players together, when we’re all in different places? The insurers are making money, the hospitals are scraping by, the docs are seeing their reimburement decrease and their malpractice insurance climb – where can we create the mandate to make real change happen???

  6. I had breast cancer. Choice of doctors? I went to the first surgeon who would take me within a week. I would call and get 3 month waits for an appointment! Cancer progresses in three months! Duh! This is in America!

    I have since treated myself with diet, and I sought help from aalternative practitioner and not only am I cancer free but I LOOK much healthier and feel much healthier. My body looks better at 51, than it did at 21! There is no focus in this country on preventative care or true HEALTH care. It is SICK care. If it is true that doctors in the UK get bonuses for IMPROVING the health of patients –that is the way to go. Our S.A.D. (standard American diet) is killing us! AND there is so much known about prevention of things like breast cancer that is not common knowledge in mainstream America–like there is a simple urine test that can predict risk, and if found to be at risk, dietary changes can shift that risk! I did it! Yet my GYN put her hand up to me and wouldn’t look at my test results! After all, let’s keep people sick–give them drugs that make them sicker and dependent on the doctors.

    All other problems aside, first, we need a shift toward PREVENTION in this country. That is where we need to change and the rest may follow suit!


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