Solving the OSFA Problem: Process Standards or Standard Processes?

Journalists often ask me to summarize the future of health care in one word. To me, the word is diverse. The realm of possibilities for delivering good medical services is growing at warp speed. Why? I believe the #1 reason is our new knowledge about genetic and molecular characteristics of common medical problems. Clinicians have a growing array of tools to identify the biologic instructions built into an unhealthy cell. With this information, they can select an intervention that interferes with the pathological process—bypassing the historically common approach of trial-and-error.

Diseases that were once thought to be the same in all patients are now recognized as being different conditions requiring different treatments, even though they have the same physical appearances. Simultaneously, clinical protocols are shifting from seeking cures to managing chronic conditions. The one-size-fits-all (OSFA) paradigm of 20th century medicine is rapidly yielding to personalized health care that reflects differences in patients and their diseases. The new disease model improves quality and reduces costs in a variety of ways, such as matching a disease’s specific biological characteristics with a drug specifically targeted to interfere in the disease process.

Believing that the medical care system should be organized to support state-of-the-art medical science, I am disappointed because recent reforms reflect OSFA thinking. Providers and payers are being pushed to fall within narrow, rigid guidelines while the scope of good medical science is expanding. For example, I do not see evidence that reform’s approach to comparative effectiveness research is sensitive to the emerging principles of personalized medicine. I also fear that reform’s regulatory mechanisms will not be able to keep up with the rapid changes in clinical science. Guidelines are likely to be outdated by the time they are adopted.

I propose a radical shift in thinking about the best way to reduce costs and improve quality—by replacing the imposition of performance standards across all providers with the expectation of standardizing performance within each individual provider organization. (For details, see http://bit.ly/aG9Zuq.) Rather than telling providers what OSFA results they must achieve to be reimbursed and assuming that they will figure out how to meet the standards, let’s require health care organizations to use proven performance improvement tools and assume that they will do the right things because they are doing things the right way.


In other words, the current approach to reform is headed in the wrong direction. It does not reflect the diversity of possibilities for improvement in American health care. Reform shouldn’t be based on OSFA outcome standards. Instead, I think that reform policy should promote business processes that help producers to do the best possible job. What do you think?