Quality of Care

Back in the 70's, competitive marching bands came into vogue in Western Pennsylvania. Let me explain the before and after of this phenomenon: Before there were competitions, bands were made up of  nearly 10 times more students than they typically have today. My bands ranged in size from 120 to 185 students. Once competition came into play, the borderline students were not able to survive.  Consequently, it is not unusual now to have 20 students or less in a band.

What's happening in medicine and in health care overall?  The Government is taking a three-pronged approach to improve quality in health care:

1.  They are pushing quality through public reporting.  (Check a website near you.)

2.  Enforcing quality through the False Claims Act.  (Check a prison near you.)

3.  Incentivizing quality through payment reform. (Check a checkbook near you.)

Senator Chuck Grassley is quoted as saying, "Today, Medicare rewards poor quality care.  That is just plain wrong, and we need to address this problem."

HMO's are currently embracing "pay for performance" plans for physicians and hospitals.  Medicare is introducing value-based purchase plans.  Medicare is proposing the linking of quality outcomes to physician payments.

As I have written before, hospitals will no longer be paid for hospital acquired conditions. That seems like a rather simple fix, but to appropriately determine if the condition was not acquired at the hospital, extensive testing must be added pre-admission at considerable costs to the hospitals. 

James G. Sheehan, Medicaid Inspector General of New York said, "We are reviewing assorted sources of quality information on your facility to see what it says and if it is consistent.  You should be doing the same."  

Except for the financial implications, not unlike my competitive band story, the goal was to work toward perfection. The public reporting of quality of care is intended to:

1.  Correct inappropriate behavior

2.  Identify overpayment's

3. Deny payments

The False Claims Act, on the other hand has different goals. When asked how he viewed the False Claims Act, Kirk Ogrosky, U.S. Deputy Chief for Health Care Fraud said, "You will see more and more physicians going to jail."   I guess the prisoners will be receiving better care.

Where's it all going?  Competitive band.  Will it improve health care delivery?  Probably, for the patients who can find the few docs and hospital that will be left?  I recently had a conversation with a young computer specialist who took care of physician practices.  He said, "Doctors and hospitals haven't figured it out yet, but they are simply becoming data entry centers for 'Big Brother' as the facts and figures are accumulated to be used against them any way the payers decide to move forward."

Looking back at the school year that included gym class twice a week for the entire year, rich courses in music and art, and remembering a time when priorities included those classes intended to make every student well rounded, we have to ask, "Is education today better?" 

Maybe this is all too complicated to get our arms around, but if there are 78 million Baby Boomers, and the Medicare Trust Fund is heading toward bankruptcy, then we probably will see every rule in the book being applied to keep from paying out money, because there is simply not enough money to go around. 

Will health care improve?  Once we understand that technology is not the end all and cure all that creates healing; once we endorse prevention, wellness, optimal healing environments, and systems approaches to health and wellness, health care will improve.  I'll bet you that it will have very little to do with the rules that are unfolding right now and much more to do with the creation and acceptance of a National Health Policy.   

Comments

[e-Patient Dave (deBronkart)]

Hi - I was steered here by Paul Levy's mention of your book on the RunningAHospital blog. This post initially caught my eye because I'm involved in competitive barbershop singing, and my particular chapter is in the throes of changing to a more competitive orientation with a similar effect on number of active members.

Meanwhile, although I'm pretty new to the subject (just this year), I've become an avid learner about transforming healthcare. (I had a wild ride with grade 4 stage 4 renal cell carcinoma last year, started dismal, had high-dosage Interleuken, emerged essentially all better in six months, though the cancer did break my femur before we stopped it.) Once it was over I learned that my primary is a member of the e-Patient Working Group, and by March I'd become a member. I work in high tech, I'm a blogger, I'm an avid amateur process geek. So I see this through lots of lenses.

Your band picture caught my eye, but now I'm trying to weave the rest of your post into my thinking about all this, and into what I've learned on Levy's blog. Lots to manage.

Are you saying that by trying to go for quality, we're going to cut out a lot of "players"? Or are you saying that "the tree up which we are barking" isn't the one that will get us to the promised land?

[Scott Hodson]

The POA assessment process, the process of gathering and reporting data for the CMS Core process of care and HCAHPS measures, development and implementation of EMRs and other quality management technology, orgainizational additions to develop and implement evidence-based physician orders and clinical pathways... and many other measures that hospitals are undertaking to address the national quality and patient safety improvement imperative have undoubtedly added to their cost structure. But I have seen and been involved in some success stories related to these activities.

At one client, pneumonia mortality declined 50%, and medicare length of stay decreased nearly 2 days (saving a significant amount of cost without impacting reimbursement.) At another client, during the first week of implementation of an eICU, two "near misses" were prevented. At another, hospital acquired conditions that added an average of $3,500 the the cost of each case that happened, and processes were put in place that reduced them dramatically. Another health system grew market share by over 5 points in two years after declaring an all out Quality Revolution and competing publicly on the basis of demonstrably better quality and patient service.

When done properly, the investment in quality and patient safety can have a positive ROI! If you haven't already, maybe it would be interesting to challenge your management team to identify quality gaps that are costing you money and market share (every hospital has them.) For example I recently saw research conducted in one Midwestern hospital where they identified that the average cost to treat a catheter related blood stream infection was $91,000, whereas the average reimbursement was about $67,000 – an operational loss of $24,000. As of Oct. 1, 2008, reimbursement will be zero. And the CDC estimates that there were nearly 30,000 such cases in 1996!

I bet you can find ways to move the needle on quality AND your bottom line. Good luck!