A Lean Thinker Watches the Documentary “Escape Fire” – A Review
Last week, while flying back from my trip to Japan, I watched a video that had been recommended to me a few times (including by my local San Antonio IHI Open School friends): “Escape Fire: The Fight to Rescue American Healthcare.” It's available on different video download / streaming services, like Amazon and iTunes.
The movie does good job of documenting the problems in healthcare – poor quality and lousy patient safety, all at an expensive price tag. In fact, the movie gets a bit tiresome, spending the first 75 minutes on the problem (or different forms of healthcare problems) before talking about solutions. The discussion of the problems is a bit too scattered and unfocused (for example, problems in military and VA medicine could probably be their own documentary), as the film covers a lot of problems and identifies many villains.
The movie starts with the legendary healthcare quality advocate Dr. Don Berwick telling a story about an innovative fire fighter who saved his life while fighting a massive wildfire. The firefighter knew he couldn't outrun the fire, so he started another smaller fire that consumed the local combustable material before the larger fire arrived. This created an escape path — an “escape fire,” if you will.
I've heard the story (here is a 1999 video of Berwick telling it) and I supposed it's supposed to represent innovative “out of the box” (sorry for the cliche) thinking that leads to surprising system improvement. But, I think the analogy and story is a bit forced as it's not really revisited until the end of the film. I don't think that story creates a framework for an entire film.
There's a phrase used late in the film that might have been a better title: “From High Tech to High Touch,” which means we might do better by relying less on new drugs and new technology and, instead, focus on lower-tech styles of preventive care.
Dr. Berwick emphasizes familiar themes: that our healthcare system is too focused on disease treatment instead of prevention and health maintenance. Rather than pointing fingers, Berwick says “Everyone is doing their job but we designed the jobs wrong.”
Berwick discusses themes are are familiar to Lean thinkers:
- More care is not always better (in terms of patient outcomes, health, and quality of life), with one example being the over treatment of prostate cancer (causing impotence and incontinence in many men)
- Activity is not the same as value to the patient
- We pay for pieces of care, so we get disjointed pieces of care
The film uses an example of a relatively young woman (under 40) who developed heart problems… she had 27 catheterizations and seven stents placed, costing $1.5 million over time. But nobody was actively managing her diabetes, a chronic condition that was contributing to ongoing heart problems. The “fee for service” payment model pays 100x more for doing the stent ($1500) compared to a “healthy care” visit ($15).
They point out, later in the movie, that heart bypass is a “workaround” and the problem comes back if the patient's lifestyle doesn't change (diet and exercise).
The film points out that, by 2020, one fifth of U.S. healthcare spending will be due to conditions caused by obesity (a problem that's getting significantly worse).
Who are the many villains in this film? They include:
- Public Relations firms
- “Big Pharma” (the film points out the U.S. and New Zealand are the only two countries that allow TV ads for drugs)
- Food companies
- Dept of Agriculture subsidies on food
- Military medicine, war, pain pills
- Medicare and Medicaid price slashing
There's lots of blame to go around, I guess. Who is responsible for the system? Who is acting in bad faith to profit from the system?
Dr. Steven Nissen, from Cleveland Clinic, is quoted a lot in the movie. He says, “When HC became a business we lost our moral compass.” A former insurance industry spokesman says, “you almost forget you're providing health insurance… it's all about profits.” How is this that people lose track of their organization's mission or compass? This is the same problem that befell GM when the finance people running the company thought the primary purpose of the company was to make money (rather than the purpose being the design and production of great cars… therefore leading to money).
One example given is the pharmaceutical maker GlaxoSmithKline. When the drug Avandia was in development, the company didn't disclose data from trials that showed heart attacks increased by one third. A $3 billion settlement agreement was reached in July 2012 after many patients are harmed. Where is the moral compass of people who hide such data in the name of profits?
What are some of the proposed solutions or “escape fires”?
- More/better primary care, which might include longer appointments, as opposed to focused on patients per hour productivity for doctors.
- Change the payment system so it's not so activity and piecework based
- The movie shows how acupuncture is more effective than drugs for military pain cases (and not addictive like narcotics).
- The movie points out we can't get acupuncture at a hospital (it's not that it doesn't work, just that they currently don't get paid for that)
- Lifestyle changes for heart disease (featuring Dr. Dean Ornish‘s work that shows artery blockages can be reversed through inexpensive life style changes)
These alternative care efforts include yoga, acupuncture, meditation, and diet (Dr. Ornish and others are working to get CMS to cover alternative medicine, hoping that private insurance will follow).
Safeway, the grocery store chain, was held up as an example of a company that is encouraging and rewarding better employee health. For them, 70% of healthcare costs resulted from lifestyle choice and their costs were rising 10% per year. With their new initiatives, their costs are now flat.
The movie ends on an optimistic note: “We can change our healthcare system but not until we change the conversation.”
I'll give the movie a B+ for showing the problem, losing marks for being so unfocused and cramming so many problems into one film. I'll give the movie a B- for talking about solutions. What they showed was interesting, but I wish they had talked more about approaches like the IHI's Triple Aim measures (the issue of patient safety was really glossed over, if it was even mentioned) or actually talking about Lean and other systems thinking approaches (like aviation safety CRM practices) are helping.
Have you seen the film? If so, what did you think?