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Dear Hillary (or Mitt or …)


Dear Hillary (or Rudy or Mitt or Barack):

I know you have a lot on your mind, what with not knowing whether you are in New Hampshire or South Carolina half the time during the campaign. But I wanted to drop you a note and let you know there is a big mess in healthcare.

Hospitalists are a growing army that can bring our country patient-centered care and measurable quality outcomes, all delivered by teams of health professionals—if you and Congress can give us some help.

In case you are not totally familiar with the concept, hospital medicine is the fastest-growing specialty in American medical history. We are more than 20,000 strong, and we treat more than 30% of medical inpatients in the country. Hospitalists are right where the action is in healthcare.

We know we can do our part to change our health communities, starting with our hospitals. But we need to improve the economics of healthcare—both what we pay for and what we reward—if we are to get the right physicians to go into hospital medicine and make this a sustainable career.

So here is our wish list.

Hospitalists are at the head of the line in agreeing to be measured and in working with other health professionals and patients to set goals for ideal hospital care. We don’t mind being held accountable for our performance; we just want to be involved in ensuring we’re measured on what matters and that we have a plan for and a part in our improvement.

Insure All Americans

There are about 50 million people without health insurance, give or take a million. Everyone knows these people are sicker and die quicker. I guess the good news is that when they eventually show up in distress at our hospitals, we hospitalists jump in and do the best we can—regardless of whether they can pay for their care or not.

The problem is these uninsured patients often should have seen us days or weeks earlier, which makes it harder for us to help them. If we are fortunate enough to get a handle on the crisis, too often lack of insurance makes it harder to find doctors in the community to follow up with these needy patients.

We are working with the American Cancer Society, which has recognized that even for those who think they have insurance coverage, many times it is inadequate. If you’re unlucky enough to get the “big C” you may end up with a choice between the best care and bankruptcy—or both.

I don’t know whether the solution is to:

  • Expand the State Children’s Health Insurance Program to include all kids;
  • Extend Medicare to people at age 55 (as Sen. Joe Biden, D-Del., has suggested); or
  • Extend Medicare to those as young as 15 to get everybody covered.

I do know the time for talk is well past. It is time for leadership and action.

If you get a chance you might take a look at the November/December 2007 issue of Health Affairs. In it, experts like Victor Fuchs, Bill Roper, Bob Berenson, Len Schaeffer, and many others frame the issues of health reform in practical terms. At the very least direct your health staffer to get a copy.

Reform Payment

People should expect value in healthcare, as we do in almost everything else we buy and need. We have an outmoded payment system that insists on rewarding the doing of anything. We have to start paying for what we want.

We have to stop paying for the unit of the visit or unit of the procedure, which just leads to more visits or more procedures—even if they produce no appreciable improvement in outcomes or quality of care. We have to start figuring out what outcomes we want and reward those healthcare professionals who can produce. If we want our diabetics in good control, pay for that. Don’t pay for just seeing the diabetic patient.

The cornerstone of value-based purchasing—which is our goal—is performance measurement. Hospitalists are at the head of the line in agreeing to be measured and in working with other health professionals and patients to set goals for ideal hospital care. We don’t mind being held accountable for our performance; we just want to be involved in ensuring we’re measured on what matters and that we have a plan for and a part in our improvement.

We also question if measuring performance at the individual doctor level makes sense. We believe healthcare is a team sport. We view our role as working with the entire healthcare team to deliver measurable, quality care. Our teams and hospitals need to be held accountable for performance and outcomes—and payment for care should be commensurate with performance.

We can talk about whether this takes the form of case rates or diagnosis-related groups for physician care: Both can reward efficiency and systems improvement. Or perhaps we should aim for pay for performance or pay for outcomes that would reward effectiveness and value. The recent decree by the Centers for Medicare and Medicaid Services not to pay hospitals for so-called “never” events (hospitalization errors that should never happen) is a good start. But we need to plow those savings back into rewards for high performance.

In the short term, if you can’t change the structure of the current payment system, at least stop these annual 5% to 10% reimbursement cuts. We are young physicians at the lower end of the pay scale, and there is little room for us to cut our expenses or stop paying our medical school loans. We are the front-line doctors essential to caring for the acutely ill, especially the elderly, and we need a payment system that makes it attractive for other young doctors to join us. Throwing out across-the-board payment cuts makes it more likely the new, younger physicians will continue to choose higher-paying specialties like anesthesiology and dermatology—just when we need many more hospitalists.

Reward What You Want

We are stuck in this payment system where we only pay for direct, face-to-face, one-on-one patient care. While this is still necessary, patients, employers, and the system cry out for a different approach.

The system needs to be reworked with improved throughput and efficiency. Seamless communication and coordination of care are primary goals. Reformed infrastructure and culture should foster development of highly effective teams of healthcare professionals. Time must be built into the work day for end-of-life care, palliative care, and joint decision-making by patients and their families.

All this takes dedication, expertise, professionalism, and—most of all—time. But in a payment system that rewards scoping an orifice or cutting out a skin lesion and still hasn’t figured out how to pay for changing the system or building a team, where do you think most physicians’ work time is driven?

Nowhere is it truer than in healthcare that you get what you pay for. There is plenty of money in the U.S. healthcare system—more than $2 trillion annually. The problem is we’re funding a system that may have worked in the 1950s, and we expect it to meet 21st-century needs.

Hospitalists are young, energetic, and optimistic. We want to be part of the solution, not another self-interest group demanding our needs be met and the heck with the dysfunction they might create. We also have most of our professional lives ahead of us, and we have seen that when we work extra hard to correct our local hospital’s glitches, it helps us function better.

The problems won’t go away if we ignore them. We have no choice but to step up and take a chance at change. We challenge you to step up, be a leader, and dare to make a difference. We suggest you:

  • Figure out a way to get all Americans insured;
  • Create a value proposition in healthcare and set up a new payment system that rewards value, efficiency, and effectiveness; and
  • Reward and incentivize a new paradigm of healthcare delivered by teams of health professionals performing in functional systems of care.

There are many entrenched institutions and constituencies that will see any change as a prescription for them to lose. Hospitalists are the future. We embrace change and accept that staying in a system that is not working is not an option. We can’t predict the outcome, but when you look for partners to take the healthcare system forward, hospitalists are ready to do their share and more. But we need your help, and we need it now. TH

Dr. Wellikson is CEO of SHM.

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