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…