Maureen Lewis grew up traveling the world as the daughter of a diplomat. That early exposure to a global perspective helped set a course for her: After studying economics and earning a PhD at Johns Hopkins University, Lewis went on to spend 22 years at the World Bank, including nearly 10 years as Chief Economist of Human Development.
Lewis has spent her career advising government and private sector leaders on reforming various national programs, including those addressing education, pensions and welfare programs. But her special focus has been health systems. “I keep coming back to health,” she says, “because it’s complicated and it has an enormous impact on so many people.”
In 2015, after leaving the World Bank, Lewis co-founded Aceso Global, a Washington D.C.-based consultancy that provides advice on hospital systems’ efficiency and quality, healthcare financing, public-private partnerships, and market strategy. Clients include governments, investors and hospital operators. (Steven J. Thompson, co-founder of GHCi, is currently serving as Aceso’s interim board chair.)
Where do you most want to make a difference?
One of the things that we feel very strongly about is that hospitals have been overlooked. Hospitals tend to receive a good deal of government health spending — they are the most expensive part of the healthcare system — but organizations such as the World Bank have largely ignored them. Not entirely, but largely, and other bilateral donors have done the same, or even less. It’s very strange. It’s because in the late 1970s, there was a meeting in Alma Ata, Kazakhstan, now known as Almaty, where it was decided that what the world needed was basic healthcare for the masses; cheap care that could be sent out into rural areas where the poor people were, to help solve their problems. But my sense of the evidence, of work I’ve seen and of places I’ve visited, is that I’m not convinced it’s a model that can work without backup from a network of hospitals.
One of the reasons we set up Aceso Global is we were concerned that if you don’t take care of the hospital system, you’re missing a big part of healthcare delivery. And it’s the part that, frankly, patients really value.
Can you give an example of a project that illustrates the sort of improvements you’re after?
In Mexico, we went to a hospital and we talked to the hospital director, the line managers, and the nurses. We looked at their data and we basically said, “You have an enormous problem in your emergency room, and your operating theater is totally backed up.” And they said, “Yes, this is really a problem, we know, we just don’t know what to do about it — and, by the way, we estimate that 70 to 80 percent of the patients who come here really should be treated at a lower level facility. They don’t need a hospital. And they don’t need an emergency room.”
Our project was to look at how you could move the patients within the hospital more efficiently, and how you could use the primary healthcare clinics that people were bypassing in a more effective way.
You’re based in the U.S. Did you bring U.S. best practices to this project?
Some of patient flow is about scheduling more effectively, seeing patients more rapidly, and being able to move people out of emergency and into beds. We’ve seen this from evidence in the U.S., where just adjusting the scheduling of surgeons over the course of a week can allow you to plan much more effectively with much better outcomes — and you can accommodate the unexpected inflow of emergency patients who need surgery. These concepts haven’t been used in emerging markets.
But as importantly, there are tools that have been developed in the U.S. on patient flow, which is really a form of hospital management, that we have adapted to use with nurses. One thing that happens is that the nurse managers in the operating room don’t talk to their counterparts on the ward. They don’t know if there’s a bed available. And they don’t have a system in place to discharge patients who are ready to go home so that beds are made available for patients in the ER who need them. That sounds pretty simple. But it’s complicated and you need a system for achieving both efficient bed turnover and effective management of ER patients.
Hospitals in Mexico are quite interested in this, so we are returning to work with two hospitals to test this out and measure what the impact is. We view it as something very critical, because it’s a tool that you can use without a great deal of fanfare and it can be very much driven by the nurses themselves. And nurses run hospitals.
What sort of tools can help solve the problem?
Solutions can run from the very sophisticated modeling system all the way down to just structuring things differently and finding ways to communicate across the hospital more effectively. It can be as basic as having the cell phone numbers of the nurses on the floor. In many respects, the developing world can learn from mistakes of the Organisation for Economic Co-operation and Development (OECD) to develop solutions.
Hospitals are pretty inefficient places. It’s partly because people don’t communicate, and in emerging markets they don’t use much technology. There are obviously exceptions. But they underutilize the technology of the cell phone. There are opportunities in Mexico and elsewhere for public hospitals to improve their efficiency in the quality of care by having software on phones that allows staff to see patient records across institutions. Nurses can update forms for patient records right on their phones. In some countries, patient records are very uneven, and because they’re paper, they get lost — the kinds of things that happen with paper.
A second part of our assignment is to work with Mexico’s primary care clinics to try to broker a way that they could work with hospitals as opposed to in parallel,which is how they’re working now. The first round of patient flow we looked at was the flow within hospitals, and now we’re looking at the flow between hospitals and clinics.
In Mexico, the number one disease is diabetes. If someone goes to the emergency room and gets treated but doesn’t understand that they need dialysis, or to change their diet, or to take medication, they’re going to end up back in the ER. But if you can have somebody at a clinic who can track this patient on a periodic basis, it’s much better treatment, cheaper and more effective.
These kinds of adjustments that help the patients and the providers become more aligned could change the way the structure of the healthcare system works. That’s the ultimate goal. It’s a public system, so things change slowly. But the people we’re working with are quite committed, and they’re eager to work on this issue.
What’s been missing in how others have tried to tackle healthcare challenges?
Incentives are what drive things in healthcare. If you understand the incentives, you can predict behavior of providers and patients. Those ideas are really grounded in what I was trained in, which is economics. You need the underpinnings of incentive analysis to see what happens. Because sometimes there are multiple incentives, or there are perverse incentives. The OECD countries have become very data-intensive, and they’ve become very analysis-driven. A lot of that has been led by economists and health policy analysts who have an understanding of these relationships.
I think that’s really been missing in emerging markets. In those markets, healthcare and its complexity is not fully appreciated. That’s partly because of the structure of the systems, and partly because of the absence of analytic talent, but you just don’t see that kind of input for policy decisions, or even for the decisions of private hospitals. Both sides need some guidance as to how they should structure their delivery system and how they should structure their insurance arrangements. This is the big issue that really complements the clinical aspects of healthcare. Incentives are not so embraced or appreciated in the ER.
What are some of the “perverse incentives” in healthcare?
It basically means that you’re giving an incentive that you think it’s going to do one thing, but it leads people to behave in a different way. One example that’s very old is that if you pay for services based on fees set by providers, it’s become abundantly clear across the globe that the providers tend to exploit that arrangement, over-prescribe and provide excessive services. And so it worked in a perverse way. Now there are different kinds of incentives that payers, whether it’s the government or an insurance company, try to use to encourage better clinical behavior.
There’s also a term in behavioral psychology that has been taken on by economics called “nudges,” which has to do with the need to encourage positive behaviors. It’s the other extreme of trying to make sure that you are encouraging appropriate behaviors in terms of what you’re trying to achieve. The classic example is signing up people in the private sector for retirement insurance. Historically, employees had the opportunity to enroll in pension plans, and few did so. However, if new employees are automatically enrolled and can opt out, they are far more likely to be in the pension plan. Many more people have retirement insurance because of this “nudge.”
Those kinds of things can also help in healthcare, where you set up implicit incentives that they encourage desirable behavior.
What do you think are the biggest mistakes organizations make in partnering globally?
U.S. organizations, from equity funds to nursing professionals, are focused on the modernization of healthcare. But emerging countries are starting at a very different place. Many people in these countries have asked me, “So who has the right healthcare?” And the answer is, no one. But the second answer is, you have to go from where you are. To change, to evolve, you have to start with what you have. You can’t impose something totally new on top of what you have, because it will never be integrated.
You have to understand the country, how the healthcare system fits with the broader systems, and who the players are. You need to find the right people to partner with. And then you need to work with them in a real partnership. Otherwise, you will launch things that they can’t do, or that don’t fit with the other ways that they do things.
I am very impatient, so I understand the impatience of investors. But they need to figure out where the opportunities are where you can make a change and then work jointly together. In those circumstances, I think partnerships can have enormous impact. The middle class is rising, especially in middle-income countries, and they want good healthcare. Most are not happy with their public sector options. While considerable foreign direct investment is happening now, there’s so much potential for more.
— Leslie Brokaw
Leslie Brokaw is a contributing editor at GHCi.