Where employers use quality control to shape healthcare
By Noam N. Levey
December 15, 2014 - Los Angeles Times
Forty miles north of Seattle, in the largest building in the world, Boeing
assembles its biggest commercial airliners.
Thousands of workers on a 98-acre factory floor piece together hulking wings
and fuselage pieces, miles of electrical wiring and millions of rivets on a
production line so precisely choreographed that Boeing can roll out a new jet
every other day. The largest plane built here, the 747, has some 6 million
parts.
With similar attention to detail, Boeing has helped shape medical care in and
around Seattle, one of the healthiest regions of the country.
Employer-provided coverage is the backbone of the U.S. health system, with
more than half of Americans getting insurance through work. Most businesses,
however, are reluctant to manage medical providers as they might other key
suppliers.
It's different on Puget Sound. Boeing and other major employers here,
including Starbucks and Costco, have aggressively pushed local hospitals and
doctors to meet the kinds of rigorous standards they use to build airplanes or
brew coffee.
That has nurtured an unusual relationship between employers and medical
centers that has affected the way patients are treated for back pain, how they
are counseled for depression, even how they schedule doctors' appointments.
The results include better health, higher patient satisfaction and in some
cases lower costs, making the community a model as employers and governments
nationwide look for ways to improve care.
"In most communities, medical providers and employers don't even talk," said
Dr. Gary Kaplan, chief executive of Seattle's Virginia Mason Medical Center, one
of the nation's top hospitals. "Here, that conversation has made a profound
difference in everything we do."
Inspired in part by Boeing, Virginia Mason is among several local medical
centers that use the same quality assurance system the aircraft company relies
on at its plants, including standardized processes and precise scheduling to
boost efficiency.
That translates into a different kind of medical care for such patients as
Bob Mannschreck, a 51-year-old manager for a logistics company. He has suffered
from back pain since a skiing accident in his 20s.
When the pain worsened, radiating down his right leg and making standing
difficult, Mannschreck called Virginia Mason's Spine Clinic in downtown
Seattle.
He got an appointment right away. When he arrived for his 9:50 a.m. slot, his
70-minute session moved like a production line.
There was no wait. In the exam room, a medical assistant began to put
information about Mannschreck's pain, medications and medical history into an
electronic record within minutes.
At 10 a.m., a physical therapist arrived and began gently probing
Mannschreck's back for pain, testing his reflexes and running him through
exercises to check his mobility.
At 10:21 a.m., Dr. Alison Putnam, a rehab physician, joined them in an
unusual team system developed by the clinic.
Putnam asked the therapist to describe Mannschreck's symptoms, a
communication technique that shows patients their concerns are understood. She
then conducted a short exam of her own.
Putnam told Mannschreck the pain could be from a herniated disk or an
irritated joint in his lower back or pelvis. She suggested an anti-inflammatory
drug and four to six weeks of physical therapy.
If the pain remained or worsened, she said, he should call immediately and
they would discuss more aggressive steps, including an MRI or an injection.
Putnam finished by 10:40. In the remainder of the appointment, the therapist
worked with Mannschreck on abdominal exercises to relieve pressure on his hips
and lower back before scheduling his next therapy appointment.
Mannschreck was done by 11 a.m.
His rigidly scheduled exam was no accident. For more than a decade, Virginia
Mason, a nearly century-old community medical system, has worked to adapt a
production system pioneered by Toyota and used by Boeing to cut waste and
standardize high-quality outcomes.
Implementing the system took on new urgency when a group of Seattle-area
employers working with insurer Aetna threatened to stop using the medical center
because it was too expensive.
Instead of fighting the employers, Virginia Mason began working with them to
redesign the care they were concerned about most: treatments for back pain,
sinusitis and other common conditions that kept employees out of work.
"When we started looking at where our costs were too high and where our
inefficiencies were, we found them everywhere," said Kaplan, the chief
executive.
Patients with back pain frequently waited a month or more to get an
appointment. They were given unnecessary tests or referred to specialists when
they actually needed physical therapy. The consequences for patients were higher
bills, spotty access and uneven results.
Starbucks, which worked with Virginia Mason on spine care, demanded a
straightforward bottom line: same-day access for employees, no unnecessary
medical care and 100% customer satisfaction.
"They said this was a supply chain issue," recalled Dr. Robert Mecklenburg,
who led Virginia Mason's redesign initiative. "They expected certain standards
from their suppliers. We were no different."
Some of the changes Virginia Mason made were simple. The spine clinic began
reserving slots in the schedule for same-day appointments for patients with
acute pain.
Doctors at the clinic created a new form for ordering MRIs that requires
doctors to attest that patients meet one of eight criteria. Unnecessary imaging
drives up costs and exposes patients to potentially harmful radiation, studies
suggest.
Most revolutionary is the clinic's carefully structured system for seeing
patients like Mannschreck, which is designed to maximize use of physicians' time
and better respond to what patients want: quick care that gets them well
quickly.
A patient spends most of an exam with a therapist, who can do basic
diagnostic testing and is often better at communicating with patients than a
doctor, clinic leaders concluded.
The doctor comes into the exam after 30 minutes, gets a briefing, then
develops a care plan with the patient and therapist and can usually leave after
20 minutes.
Better use of doctors allowed Virginia Mason to eliminate backlogs nearly
overnight.
Fewer unnecessary tests and more use of therapists — which the medical center
calculated cost about $1 a minute, compared with $4 a minute for a doctor — led
to lower costs.
The more standardized, efficient system also meant better outcomes.
Virginia Mason patients with back ailments typically need four to five visits
to recover, compared with 10 nationally. The clinic's patients also return to
work more quickly, missing two days on average compared with five elsewhere,
survey data show.
That's key for employers. "Our ability to keep people healthy and get them
back to work quickly is critical," said Jeff White, director of Boeing's health
benefits strategy.
Patients also appreciate the efficiency. "When you are immobile and in pain,
time is of the essence," said Marcy Naismith, a 36-year-old interior designer
who got in right away after injuring her back lifting one of her 2-year-old
twins.
In recent years, Virginia Mason worked with other employers, including
Costco, Nordstrom and the city of Seattle, to redesign care systems for
headaches, joint pain and noncancerous breast lumps.
Similar relationships between employers and medical systems are transforming
care elsewhere in the region.
Prompted by the state of Washington, which provides coverage to some 350,000
public employees and retirees, Group Health Cooperative, another leading
Seattle-area system, implemented a groundbreaking method for improving
communication between doctors and patients who may need surgery.
North of Seattle, Boeing helped the Everett Clinic build what is considered a
national model of team-based care for very sick patients.
Now, the aviation giant is working with the state's largest health systems —
UW Medicine, Providence Health & Services and Swedish Health Services — on a
new project to deliver higher-quality, lower-cost care for about 30,000 Boeing
employees and retirees.
"When Boeing says, 'We need better care,' you listen," said Dr. Joseph
Gifford, who heads an alliance of the Providence and Swedish systems that works
with the company.
Today, businesses in a handful of states, including Minnesota, Maine, New
York and Arkansas, are similarly pushing healthcare systems to improve.
It remains unclear whether that kind of business leadership will develop
elsewhere. Few companies have as much local clout as Boeing, which employs about
80,000 people in Washington state. And few communities have as many health
systems that are willing to work with local employers as Seattle.
"You need people who are willing to sit down in a room together and work on
community problems," said Helen Darling, former longtime head of the National
Business Group on Health, an association of large employers. "That is very hard
to replicate."
But as businesses increasingly move workers to high-deductible health plans
that force them to pay more out of pocket, employers may get more engaged with
local health systems to help employees shop for care, predicted Leah Binder,
president of the Leapfrog Group, a national nonprofit formed by employers to
track hospital quality.
"Employers," she said, "may not have a choice."