By recommending changes in payment methodology to hospitals, however, MedPAC is isolating the facility from the intricate composite of systems and processes involved in transitions of care. While I realize the analogy is a bit of a stretch, this approach strikes me as similar to applying the logic of cooling to unfry an egg. A generally simple tactic to address a highly complex issue. Just as albumin has precise folds, spirals, and sheets to allow it to perform its proper function as a protein, so too must the healthcare system provide proper coordination, communication and support services to ensure proper health and well-being of patients.
Restructuring hospital payments in no way addresses the role of physicians in the hospital, physicians in the ambulatory or sub-acute setting, home-care agencies, other vendors, caregiver compliance, patient self-care, or chronic disease management. MedPAC’s proposal holds one party accountable in a scenario where only joint accountability will render the results we desire. In a recent article in the Harvard Business Review, Roger Martin eloquently describes a common coping mechanism people use to address complexity and ambiguity—simplification whenever possible. Within organizations, “When a colleague admonishes us to ‘quit complicating the issue,’ it’s not just an impatient reminder to get on with the damn job—it’s also a plea to keep the complexity at a comfortable level.”
I do not mean to imply incentives are not important; they are vital to stimulate change and manage behavior. That being said, I also believe incentive programs often beget unintended consequences and may drive undesirable behavior.
Would MedPAC’s proposal cause hospitals to become apprehensive about accepting more complex cases? Even the best severity-adjustment methods account for only a fraction of the variations among patients, so hospitals may feel compelled to screen or select out certain complex populations as opposed to relying on severity-adjustment measures to account for true differences in patient outcomes.
Don Berwick, MD, the CEO of the Institute of Healthcare Improvement (IHI), is often quoted as saying, “Every system is perfectly designed to achieve the results it gets.” If this is so, a singular focus on incentives and penalties directed toward hospitals will bring either unilateral facility actions and/or a lack of leverage to effect needed improvements in the rest of the care system.
Alternatively, the Centers for Medicare and Medicaid Systems (CMS) could focus on several areas that constructively address the interdependent systems and multiple stakeholders involved in transitions of care. CMS could:
- Adopt a public reporting system for readmission rates for hospitals according to select discharge diagnoses. Transparency likely will drive some improvements via the “Hawthorne effect,” and it will serve as a common basis for key parties discussing the issues to drive improvement;
- Advocate that public reporting should be accompanied by rigorous public education on transitions of care. Such education should include a clear outline of the complexities, interdependencies, and pitfalls common to care transitions, and should also include clear steps patients and caregivers can take to play an effective role in the process;
- Participate in the development of improvement tools to address readmission rates. IHI is a terrific example of an organization that has created such a device to improve hospital mortality rates. Their Mortality Diagnostic Tool identifies potentially avoidable hospital deaths;
- Sponsor collaborative meetings with key industry organizations to discuss the issues, gain consensus on standards and expectations, and promote necessary change; and
- Take the framework of reporting, education, improvement tools and practice standards to create aligned incentives across facilities, providers, vendors, and beneficiaries.