The productivity conundrum

We struggle in health care now as much with the system as we do with patient care.  Fiscal pressures, mounting demands for treatment, new innovative treatments – all form an ever increasing set of expectations of and by patients, funders, and providers alike.

We are being challenged to be more productive.  To do more with the same or less.  “Bending the cost care curve” implicitly referenced the need to provide more services with the same amount of funding.  Because many of the costs of health care are fixed – drugs, the cost of tests, implants and devices, and so on, the idea of doing more with less will require real change.  And we will need more production; demographic changes and the expectations of patients, in addition to continued population growth, mean absolute demands for health care will INCREASE, not decrease.

Asking health care providers to work harder to provide more services in the same amount of time will cost more, not the same.  Speeding the throughput of surgical procedures requires more of the equipment, drugs, implants, beds, and labour to provide those services.  Doing 6 procedures in the time previously required to do 4 means that 50 percent more of the required supplies are needed for those procedures – so while higher productivity means each procedure may use less of a physician or nurse’s time, doing more in health care means using more to do it.  The assumption that being more productive reduces cost in health care is false, unless the cost per unit service delivery is reduced so that total expenditure remains unchanged.  I don’t suspect that medical equipment or drug manufacturers, or those who build hospitals are willing to take a write-down on their products – not when the population of Canada is less than the population of California – so much for the “power” of leverage buying.

Increased productivity without increased cost, without other change, is magical thinking.  If increased services are to be delivered without increasing costs in health care that requires a clear and direct reduction in other costs in health care.  Reducing the cost of labour in health care is one approach–directly writing-down compensation rates for doctors, nurses, administrators, physiotherapists, and all of the other professionals who provide health care, orfor for a removal of a substantial number of these providers from the health care system, with the implicit, but difficult assumption that those who remain will work more efficiently and increase their productivity. Alternatively, and perhaps more thoughtfully, we could take steps to reduce other costs  – eliminate tests and procedures that have no clinical efficacy, realize the productivity dividend that has resulted from technology, eliminate waste and duplication, reduce administrative overheads, shift work to less expensive venues, reduce institutional dependency, shift work to less expensive providers at the same rate of productivity.   Change is difficult but there is a fundamental truism that trumps all others, that there is no action without consequence, either intended or unintended.  Simple solutions for complex problems, in health care as any where else, are always wrong.