On June 6, 1944, Allied troops launched the climactic D-Day invasion of Hitler’s Fortress Europe, signaling the beginning of the end of World War II. As we mark the 75th anniversary of the invasion, three D-Day lessons suggest an approach to tackle another formidable enemy: inefficiency lurking inside our healthcare system.
Lesson #1: Develop a clear, understandable objective that “the troops” can rally around.
The Allies in WWII had a clear objective – to free the world of Hitler’s tyranny. The troops understood the final objective and believed in it. Today, what is this important, overarching goal for U.S. healthcare? Is it to have the cheapest healthcare? The most technologically advanced care regardless of cost? In our view, the goal should be to have the highest value healthcare. Value is defined as a ratio of quality / cost. In healthcare, quality includes measurable elements such as the patient’s outcome (after considering individual risk factors), the time it takes for the patient to return to normal activity, complication rates and patient satisfaction. Cost, on the other hand, should encompass spending for all resources used to achieve the quality outcome – and more spending often isn’t better. We must measure the cost of an entire episode of care (such as a knee replacement or heart surgery) – not the individual prices for the MRI, EKG or lab tests. Focusing on individual items is like calculating the overall value of your home based upon what you paid for the deck. Rather, we need to look at total costs, which include physician and hospital fees, tests, procedures, rehabilitation and home care. We must keep a laser focus on highest value.
Lesson #2. Devise a solid, flexible and innovative plan of attack.
The Allies planned extensively for the D-Day assault, and assured that all the participants were well trained and clear about expectations. But top leadership gave the troops the flexibility to make decisions to adjust the original plan when they hit the ground. As an example, most U.S. airborne paratroopers did not land in their planned location on D-Day and many did not even have their weapons. But troopers grouped together, scrounged for weapons and continued on because they knew their overall objective. Meanwhile, the Nazi’s adhered to hierarchical German military tradition, which meant that only an order from Hitler himself allowed for action. In healthcare, multiple examples of central pricing controls also block innovation on the front lines: Medicare rules on only paying certain types of providers and settings regardless of patient outcomes; complicated centralized pricing formulas for discrete medical services rather than for total episodes of care; detailed steps required for providers to receive government IT support; complex billing codes where even independent experts cannot agree on the correct code for a given patient. If we paid for bundles of services with a quality bonus, rather than each individual test or procedure, and with the price of the bundle reflecting what it actually costs to deliver care at high-value organizations, medical centers around the country would have an incentive to innovate to achieve better patient outcomes while using fewer resources – innovate to higher value.
Lesson #3: Complex systems function most efficiently through a coordinated team effort.
It took a team for the Allies to prevail on D-Day. The day was not won by any one branch of the service or by any one country alone. It was won by coordinated efforts of many countries with infantry, paratroopers, Navy and Air Corps. Historian Stephen Ambrose argues, “From the moment of taking the responsibilities as Supreme Commander, he (General Eisenhower) insisted on teamwork. … In the end, the insistence on teamwork was the key to victory.” Teamwork is also the key to overcoming inefficiency in health care. Medical centers that are organized around integrated, multi-specialty physician group practices with linked hospital services exemplify the type of teamwork that produces higher quality, lower cost results. These medical centers tend to do well on value – producing better patient outcomes while using fewer expensive resources, such as the number of hospital admissions or days spent in the ICU.
D-Day launched the victory over Hitler’s oppression. The offensive was initiated with a clearly understood objective; excellent, flexible planning and execution; and coordinated implementation through teamwork. Seventy-five years later, we could use these WWII lessons to improve the value of U.S. healthcare.