Chasing the Rabbit: Official Blog by Author Steven Spear

Excerpt: As a health care reform package rumbles through Congress, how can we judge its potential to make things better?  Here are four questions to ask.

1: Is the coverage problem separated from the problem of providing low cost, high quality care?

2: Are normal costs separated from catastrophic situations?

3: Can payers and patients identify the best sources of value and choose among them?

4: Do providers have incentives to provide the right care in the right way effectively and efficiently and are there penalties for poorly delivering value (a far different question than pay for performance based on subscribing to protocols).

If so, we have a chance for success.  If not, more money will be wasted providing care that is inadequate, denying care to those who need it.

Main Text: As health care reform rumbles through the nation’s capital, legislators will inevitably throw what they think are ’solutions’ into the mix.  How do we judge whether they are likely to solve the problems we face?  Here are some criteria to consider (Please let me know what you think of these and what else we might add.)

1: Caring for Those Who Cannot Care for Themselves: Does the package separate problems of access and ability to pay from providing high quality low cost care?

Ability to pay: There are some people who are simply unable to afford life’s necessities.  As a society, we’ve grappled with those issues privately (charity) and publicly (wealth transfer programs for food, clothing, housing, and education) in the past.  Therefore, for those too poor to pay for themselves, will they get resources to pay for what they cannot afford by themselves?

2: Normal and Catastrophic Conditions: Does the package separate ‘normal’ health care needs from crisis/catastrophic conditions?

Predictable costs: All of us need our teeth cleaned twice a year, regular eye exams, physicals, colon cancer screening at age 50, and inoculations.  These are as predictable as are housing, clothing, food, utilities,  and tuition.  Does the package give people incentives/reasons to budget for routine care like they do for all other routine expenses?

Unpredictable costs: We regularly help people who get hit by catastrophic situations: Tornadoes, floods, wild fires, and hurricanes.  There are some medical situations–accidents, major illnesses, etc. which are physicallly, emotionally, and financially devastating.  Does the package ’socialize’ those situations so we each bear some of the burden for extraordinary suffering?

3: Patient/Payer Decision Making: Does the package give patients and payers the ability to determine where to go for care?

I joke that it was not Toyota that proved the undoing of General Motors, it was Consumer Reports, Road and Track, Car and Driver, and other such magazines.  These  gave consumers the ability to compare across models to quickly and inexpensively determine which best met their needs at the fairest prices.  They spent money were they perceived value, didn’t where they didn’t, and the rest is history.

Right now, it is nearly impossible to do the same in health care.  My daughter fell from the monkey bars in a play ground and needed to be taken to an emergency department for an x ray and evaluation.  Unable to discover the quality-cost profile of local hospitals in treating pediatric orthopedic trauma, I went to the one nearest by and with easiest parking. Not the best way to choose a provider.

Therefore, does the health care reform package facilitate defining care by value provided (not by services consumed) AND does it give patients and payers the ability to choose providers based on those measures?

4: Provider incentives: There is a wealth of evidence proving that there is HUGE variation in the quality of care provided and the cost of providing that care.  Some deliver great value for low cost while others burn resources yet still harm patients.

There is also overwhelming evidence that this is a mutable problem, that when providers adopt sophisticated approaches to managing the delivery of care, they can achieve simultaneous, orders of magnitude improvement along the dimensions of access, quality, safety, responsiveness, and cost.

The problem?  With a reimbursement system calibrated off of time and resources consumed, not value delivered, many providers (particularly well funded academic medical centers that have three missions of research, teaching, and clinical care) pay no penalty for being lousy and enjoy little benefit from being outstanding.  Therefore, does the reform package create rewards for being good, pain for being bad so that patients, payers, and resources flow to outstanding providers, allowing/forcing the under achievers to wither?

In sum, the American health care system is a mess.  Too few people have access, those who do pay a lot, but the care they receive is often absymal relative to what they rightfully expect given the great science and technology at our disposal.  These problems are all solveable, but they require sensible approaches and not a willy nilly dumping of every pet idea into the mix.

Related posts:

1. Outcomes Measurement: The Linchpin of Healthcare Reform
2. Healthcare Reform Linchpin: Measure Value Added and Reimburse Accordingly…
3. Measuring Therapeutic Effectiveness and Cost–One Part of Better Care for All
4. Brooks Right, Krugman Wrong on Healthcare ‘Reform’ Legislation
5. Bob Herbert: A Less Than Honest Policy–Sen. Healthcare ‘Reform’