The 80-20 Rule in Medicine

I had a "liberal" education before going into medicine, which at the time meant absolutely no courses at all in business or management. In Medical School the presumption was we were all going to be like our professors and stay in academics, so worrying about money was beneath us ( an attitude which explains much of what goes on in medicine). Medical school used to teach us that we did everything we could for THE patient, not so much for the population as a whole. Cost was barely mentioned, and careers were made by developing small improvements in a treatment or procedure.

It was only much later that I learned how business people see things. One of the first things I learned is the 80/20 rule, which says that 20% of the people in any organization do 80% of the work, or 20% of your customers result in 80% of the profits. Like most such rules, it is surprisingly useful across broad areas.

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If you consider populations as a whole, instead of individual patients, the 80/20 rule also applies to medicine. That is, 80% of the overall improvement of the population comes from about 20% of the healthcare expenditures. Simple, cheap, and population based interventions, like vaccinations, treatment of high blood pressure, antibiotics for infections, and well baby care make vast improvements in population health statistics. Almost all of this care can be given by General Practice doctors, cheaply, conveniently and with little or no risk.

The other 80% of the healthcare is the problem. For example up to 50% of medicare expenditures are used during the last year of a person's life. This expenditure, for last line chemotherapy, dialysis, intensive care units, and other expensive procedures might save some individuals, but on average does not help the patient or the health of the population in general.

Almost all the expensive care in the last year of life is given by specialists.

Dr. Berwick is one of the thought leaders in viewing medicine from this population perspective. This type of thinking is the intellectual driving force behind Obamacare.

For the specialist, trying (for example) to place a coil in a 3mm aneurysm in a tiny vessel in the brain, such thinking might as well be from Mars.

More to come.

The 80-20 Rule in Medicine

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