Idon’t know about you, but sometimes I feel as if we are living in an era of information overload when it comes to all of the ideas that are spilling out of Washington and elsewhere under the sobriquet of “healthcare reform.” I thought we should take a few minutes and try to bring all these proposals into focus.
There is an ideal, almost a nirvana, that is being sought. This would include access with a very big “A” to include most, if not all, Americans, and would recognize key differences in patients (comorbidities), and would incentivize value (e.g., quality and cost), and promote evidence-based medicine (EBM) instead of the usual and customary.
That is a far cry from the system that we currently function in. The reality of today is much simpler, at least for the payment part of the system. A hospital or a doctor does something specific, such as a procedure or a visit, and whoever provides the care submits the bill. It is finite and usually involves a small group of individuals or facilities. Because it is simple and to the point, it allows small hospitals and the generally fragmented physician practices to be in the game.
Unfortunately, this system of payment and reward has not led us to the outcomes or performance that our country’s leaders or businesses, and more and more our patients, think we should be getting for our $2.2 trillion. Part of this is due to the fragmentation and variability in how healthcare currently is delivered. More unfortunate is the reality of the disconnect between patients and providers, and the complexity of care. In most healthcare communities, patients can wander through the course of their care to many providers and facilities, most of which have no common information system or business relationship.
One solution that is being considered in Washington is bundling. When policy wonks talk about bundling of payment for an episode of care, they are envisioning a world in which whoever is paying for care (Medicare, insurers, etc.) can pay one fee that would encompass the care provided by all providers, all facilities, and over a broad timeframe (e.g., hospitalization, then 30 days post-discharge). That might work for Mayo in southern Minnesota, Geisinger in northeast Pennsylvania, or Kaiser in Northern California, but just how would it work in the vast majority of places in the U.S.?
If a patient’s care involves two or three separate facilities or a number of providers in the hospital, and it spans as many as 30 days after discharge, how would you assign responsibility for flaws in the patient’s care or the need for additional services? And where is the patient responsibility in all of this?
Knowing all of this, is Congress really ready to write new regulations and pivot 180 degrees on the current system? Glenn Steele, CEO of Geisinger Health System and a recognized leader in a forward-thinking organization, has said, “We probably ought to have a system where we can be innovative, rather than just a new set of rules.”
In some ways, healthcare reform already is moving forward. The Centers for Medicare and Medicaid Services (CMS) has enacted “never events” in an attempt to improve performance by withholding payment for incidents Medicare thinks just shouldn’t happen (e.g., wrong-side surgery, some hospital-acquired infections).
In addition, 14 communities are ready to perform three-year “comparative effectiveness” trials to attempt to coordinate care among disparate sectors of the healthcare continuum. The research model is looking for ways to deliver optimum care in less-organized sectors of healthcare.