The Cheesecake Factory solution for health care?

What does judging mashed potatoes to be awkwardly piled too high have to do with figuring out a better way to deliver health care in an era of exploding costs and complex medical procedures? A lot more than you might think, especially when the analogy is deployed by Atul Gawande, a Boston surgeon by day who writes lengthy health care-related pieces for the New Yorker in his spare time.

In Gawande’s latest New Yorker offering, he uses the elaborate systems that are in place in the operation of a Cheesecake Factory restaurant to explain how a similar systematic reworking of health care delivery is now underway through the formation of big hospital chains — and why we should (mostly) be thankful for it.

Of course, it’s not quite that black and white. Gawande points out all the potential downsides to the merger mania that has taken hold in health care (he artfully cites outsized market power to set prices as one downside without naming his own employer, Partners HealthCare, as the biggest target of such criticism in Massachusetts). But his piece is much more focused on the upsides to the homogenization of health care in the era of what he calls “Big Medicine.”

Just as the Cheesecake Factory’s highly refined systems for purchasing and preparing decent-quality restaurant food has brought very good, if not exactly high-end, dining to the masses at affordable prices, so, too, he says, can proven systems of good quality medical practice, deployed at large scale, ensure good health care that doesn’t break the bank.  Gawande illustrates the point by describing his mother’s recent experience with a knee replacement operation at Brigham and Women’s Hospital, where he works. She was under the care of a surgeon who has disrupted the status quo there by insisting that most knee replacement surgeries at the hospital follow a default system for such procedures, including using the same brand of artificial joint and the same proven rehab protocol. The result, says Gawande: better patient outcomes and lowered cost.

Gawande also spends some time in the “ICU command center” for Steward Health Care, a building outside Boston filled with millions of dollars of monitoring technology where a team of doctors and nurses monitors patients in the intensive care units at the 10 hospitals owned by the for-profit chain. Some of the clinicians on the ground in the hospitals resent the Big-Brother-is-watching aspect to the system, but others welcome the back-up help, and Gawande observes as the oversight system catches things that make a difference for patient care. CommonWealth’s current issue includes a look at Steward’s aggressive arrival on the local health care scene.

The piece offers lots of food for thought, especially as Massachusetts enters a new phase of health care reform with yesterday’s signing by Gov. Deval Patrick of cost-containment legislation.

“The theory the country is about to test is that chains will make us better and more efficient,” Gawande writes. Those pushing for more mergers “want to create Cheesecake Factories for health care. The question is whether the medical counterparts to Mauricio at the broiler station—the clinicians in the operating rooms, in the medical offices, in the intensive-care units—will go along with the plan.”

                                                                                                                                                –MICHAEL JONAS


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