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  • “Gawande’s Kitchen”

    Posted by Jonathan on August 24th, 2012 (All posts by )

    An insightful critique:

    But there is a much more important question being ignored by Gawande — How well does The Cheesecake Factory analogy really apply to health care? We can see how similar the kitchen is to an operating room — lots of busy people rushing about in a sterile environment, each concentrated on a task. But what about the rest of the “system?”
     
    At The Cheesecake Factory, the customer is the diner. That’s who orders the service, pays the bill, and comes back again if he is happy. That is who all of the efficient, standardized food preparation is designed to please.
     
    In Gawande’s ideal health care model, however, the customer isn’t the patient, but the third-party payer, be it an insurer or government. Let’s call that entity the TPP. The TPP never enters the kitchen. The TTP has no idea what happens in there, and doesn’t really care as long as the steak is cooked to his satisfaction and the tab is affordable.
     
    In this model, the patient is actually the steak. It is the steak who is processed in the kitchen. It is the steak that is cut and cooked and placed on a platter. The steak doesn’t get a vote. Nobody cares if the steak is happy. The steak doesn’t pay the bill. The steak isn’t coming back again.
     
    So here we are in Dr. Gawande’s kitchen, where you and I are slabs of meat and Chef Gawande will cook us to the specifications of his TPP customers — satisfaction guaranteed.

    Worth reading in full.

    (Via The Right Coast.)

     

    3 Responses to ““Gawande’s Kitchen””

    1. David Foster Says:

      It sounds like Gawande has reinvented Taylorism. I wonder if he knows what that term means, or its history, or anything about the things now going on in the Lean world. A search of the article shows no occurrences of either the words “Taylor” or “Lean.”

      No question that healthcare could benefit from the GOOD half of Taylorism–more focus on the scientific study of how work is done and could be improved–but Gawande seems to want to go to the dark side of Taylorism, the top-down micromanagement of activity and the separation of thinking from doing.

      If he wants to use an analogy, Cheesecake Factory is not a good one. Try a repair facility working on highly complex products–airliners or locomotives, say–or a job-shop manufacturing facility. But even these do not come close to having to deal with the range of problems that a physician or medical facility will encounter.

      Peter Drucker asserted that hospitals are the most complex organizations in existence.

    2. Mike_K Says:

      Hospitals are also poorly run. A possible exception is Kaiser Permanente, which used to get the lowest quintile of doctors in skill and income. Since all doctors have been affected by the price controls of the past 30 years, Kaiser now recruits with the best. Most of Kaiser’s innovation, I believe, have to do with outpatient care, however. When I was running a trauma center , we would get a Kaiser patient from time to time. I always called and they never wanted the patient transferred.

      My own preference, which I have described elsewhere in a series of posts a couple of years ago, is the French system. France is a large country with a rather diverse population and its health care is highly rated by patients although cost is moderate. The French Social SEcurity system is in trouble but that is due to the pension aspect and high unemployment.

      The basis of the French system is fee for service, the bogeyman of all US reformers. It is supposed to drive costs up by the mechanism described by Gawande. In fact, it places the patient as the customer and not the steak. They achieve cost control in two ways. The national plan establishes a fee schedule, which they agree to pay the patient bases on a list of services. In this way, it resembles what used to be called “indemnity” insurance for health care in this country. The payment, in tat case to the doctor, was unpopular in later years as fee inflation developed. The French deal with this by paying the fee to the patient AFTER the patient has paid the doctor or hospital. In the case of high hospital bills, there is a system called , French, “One third to pay.” It pays part of the bill in advance.

      Doctors are allowed to charge more than the fee schedule if they can get the patient to pay. They must post all charges in view in the office. The actual fees are lower than the US but medical school in France is free and is usually does not require a college degree to apply. the doctors who agree to accept the fee schedule as full payment are provided incentives, such as paid holidays and pensions.

      I could imagine that the US could do something with tuition and student loans in such a plan. France, of course, is a country that loves centralized control. However the chief characteristic of its health plan is the voluntary nature. There are large HMO-like structures in the cities and for the poor but the patient satisfaction approaches that of Cheesecake Factory.

      I doubt seriously if Gawande has ever had any experience in a setting other than a university system.

    3. Mike_K Says:

      My link didn’t work. It is here.