哈佛商學院教授暨《哈佛商業評論》文章〈為醫界把脈〉（How to Solve the Cost Crisis in Health Care）的作者麥可．波特（Michael Porter）和羅伯．柯普朗（Robert S. Kaplan）說明，為什麼醫療機構必須從正確的衡量方法開始著手。
Michael Porter and Robert S. Kaplan, Harvard Business School professors and authors of the HBR article "How to Solve the Cost Crisis in Health Care," explain why providers must start with proper measurement.
Adi Ignatius: Welcome to The Idea from Harvard Business Review. I’m Adi Ignatius, editor in chief, and joining me toady are Harvard Business School professors Robert Kaplan and Michael Porter to talk about how to solve the cost crisis in health care. Mike, let me start with you. What is the problem you’re trying to solve?
Michael Porter: Well Adi, as you know, cost in health care are out of control—all over the world, not just in the United States. An enormous share of our GDP is tied up in health care. It’s growing every year. A lot of these problems, some of the problem has to do with aging populations and medical technology, but what we’ve discovered is actually a major part of the problem is incredible surprising. And that is that organizations in health care don’t know how to measure their cost properly.
They confuse cost with how much they get paid. They add up cost around departments, not around the patient, and the patient’s need, and meeting the patient’s need. They allocate cost improperly, with all kinds of biases that really confuse what the actual cost are. And because of this, efforts in the past at cost reduction in health care have been completely ineffective—across the board price cuts when that makes no sense, arbitrary reductions in services where that makes no sense.
And really, the inability to get visibility on the things that could really make the system more productive.
Robert Kaplan: Let me just add one more dimension to what Mike said to the problem is that people don’t even agree on what they mean by costs. When the government talks about cost, they mean their costs, what they have to spend to reimburse providers. And so when they talk about reducing costs, they mean how can we starve the beast and reduce the payments into the system.
Consumers think about their costs, what it costs them to get medical care or to pay for their insurance. But the correct definition of cost is the cost incurred within the system by the provider organizations themselves. And the only way to get fundamental reform is to work on the cost within that system and solving the problems that Mike described.
Adi Ignatius: OK, so how do we fix it?
Robert Kaplan: Well, the solution, actually, is not that complex. The framework is simple, though it did take me 20 years to get this simple.
And it focuses on the patient as the unit of analysis. It’s the patient that’s triggering the demand for all these medical resources. And so that has to be your fundamental costing unit. And we get at it in a two-stage procedure. One is to just look at the administrative and clinical processes that a patient goes through over a complete cycle of care, when they first presented with symptoms until the conclusion of their care, and just map all the processes that are involved in that and identify the resources, which are the physicians, and the nurses, and the administrators, but also the equipment and the facilities that are used at treating the patient at each of these processes.
Then the second part is just to measure the cost of each of these resources. What does it cost to supply a physician, a nurse, a clerk, a piece of equipment? And then you measure how much time that the patient spends with each of these resources, multiplies that by the cost, and that gives you the cost over a complete cycle of care.
Michael Porter: And some of the powerful things we’ve learned is you have to do that measurement around a set of patients with a given medical condition. So you want to understand the cost of treating breast cancer or diabetes, rather than accumulate the cost of providing a particular service, like an outpatient visit or an image. And when you do it around the patient’s medical condition, then you can compare the cost to the outcomes and start asking value questions.
Are we creating value? Do we need to do this process in order to improve the outcome? And that discussion, as astonishing as you would believe, has never happened in health care. There’s never been the information to have that discussion that really compares costs and outcomes.
Adi Ignatius: So this sounds like a great plan if you’re building a health care system from the ground up. Let’s talk practical. I mean, how would you reform a system like the one in the US, with its messy, that has entrenched interest? How would you change it to be more like this?
Robert Kaplan: What we have found is that the process of just going through, doing the process maps, and agreeing which resources are done at which process, and what does it cost to supply the resource, this is not controversial. I mean, you can get back to the data. And it actually has provided a great forum by which these warring factions, you know, administrators saying cut costs, and clinicians saying, hey, we cure and save patients, start to speak the same language. And so the transformation will come from within.
It’s going to come from within these various provider organizations because this is what they should be doing and should have been doing. And it’s kind of obvious. I mean, we’ve found that the clinicians buy into this because it corresponds to what they’re doing. There’s also pressure, of course, on the outside, from various insurance companies and from the government, to cut the payments. And the only way these forces are going to come together is if the provider organizations get more efficient, get more focused, and deliver the same or better care at lower cost because their reimbursements are not going to continue to escalate the way they have over the past several decades.
Michael Porter: Adi, you know, I’ve been working now for about a decade in health care. And this article is the most optimistic single thing about health care that, certainly, I’ve ever done. Because it really shows that we can make tremendous improvements in caring for patients and do it with a lot less resources, and nobody, intrinsically, has to take a pay cut. And so many people feel that the health care problem is intractable. The cost problem is intractable. It’s driven by forces beyond our control—it’s actually isn’t. We can actually solve this problem.
Adi Ignatius: And what would this do? Do you have any estimate, if a system like this rolled out across the US, what would that do in terms of health care and in terms of overall costs?
Robert Kaplan: Given the state of the industry today, and its lack of understanding of the cost of doing business, having this clear, transparent, an actionable view on what it’s costing them to deliver care, where the unused capacity is, where we’re using the wrong medical resources to treat a given condition, doing things in expensive facilities rather than much less expensive at suburban clinics, I’d be surprised if we couldn’t get at least 10% or 20% of the cost out of the system without sacrificing outcomes and, as Mike was saying on the cycle times, actually improving outcomes at the same time.
Adi Ignatius: I know that you’ve been involved in some pilot projects. And I’d love to know briefly what you’re finding from that.
Robert Kaplan: We’re currently working with seven or eight pilot sites, about half of which are focused on the same procedure, which is a total knee replacement. And so we have the opportunity of seeing the different processes they’re using, the different resources they’re using at each of these processes, and compare their outcomes and costs.
The clinic that we’re working with in Germany was able to deliver comparable outcomes to the US using the 25% of the resources. Now some of that is actually prices, they’re paying a little bit less for their nurses and physicians than we do in the US, but there are productivity differences of somewhere between two, to four, to one, just in the way they’re organizing the delivery of medical care.
Michael Porter: And we are facing now a very growing demand for more and more pilots. So I think the health care field is ready for this. This is the moment, the circumstances are right, and the challenge now is to help make this actionable, help make it as easy as possible to implement, help provide the tools and the support to allow organizations to actually implement this. But 10 years from now, every major health care delivery organization is going to do this. They have to.
Adi Ignatius: So it’s very intriguing to me that the two of you have come together on this topic. Can you tell me a little bit about this collaboration came about?
Michael Porter: Well, I stumbled into this field perhaps a decade ago, really because a colleague of mine had a child that was extremely sick. And I spent day, after day, after day talking with her about her child and what was going onto him as he was migrating his way through the health care system. And we started getting interested in it, and talking about it, and that led to some work.
So I’ve been at this for a while but I had never gotten close enough to really understand this cost issue until perhaps two years ago, when I started asking questions, that seemed obvious to me, that nobody could ever answer. Like, oh, what’s the cost of doing this service in this facility versus that facility? And everybody would clear their throats and wave their hands, but they really didn’t know. And so I get this hunch and asked Bob if he had ever done any work on costing in health care.
And he said, well, he’d been close to doing work, but had never quite had a chance to really get under the tent in a real important organization. I had some great relationships with some leading medical centers. And so we just agreed that we would give this a shot. And it’s just been enormously gratifying to work with Bob and the rate of progress here has been really breathtaking.
Adi Ignatius: That was fascinating. I want to thank both of you for being with us today. That was The Idea from Harvard Business Review. For more, go to hbr.org.