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Wachter’s World


NATIONAL HARBOR, Md.—Democrats and Republicans have trumpeted that unprecedented changes in the healthcare system are on the way, but the dean of HM cautions that significant change is still years away.

“The reform bill, to my mind, mostly kicked the hard decision for cost, quality, and safety down the road,” said Bob Wachter, MD, MHM, chief of the hospitalist division, professor, and associate chair of the Department of Medicine at the University of California at San Francisco. “All of these issues have been raised, though.”

Dr. Wachter, former SHM president, author of the blog Wachter’s World (www.wachters, and recently named the 10th-most-powerful physician executive in the nation by Modern Healthcare, used his annual HM10 address to paint a cautiously optimistic picture of HM playing a leading role in quality, safety, and innovation in the delivery of healthcare.

“It is a completely open question, whether we will be capable of snapping our fingers and creating a set of incentives or policy drivers that will allow the creation of the next Geisinger [Health System] without waiting 50 years,” Dr. Wachter said. “These cultures take a long time to develop. It’s not just about the [organizational] chart and the way money flows. You have to develop the culture of shared governance.”

In what has become a rite, Dr. Wachter gives the closing address at SHM’s annual meeting. This year’s title: “Use Your Words: Understanding the New Language of Healthcare Reform.” He focused most of his speech on finding the balance between high-quality and low-cost patient care, particularly when viewed through the prism of the “cost curve,” the economic principle that measures benefits against their cost.

Medical care on the “flat part of the curve” equates to tests, procedures, or other engagements that might have prophylactic value but little clinical benefit. From a purely clinical point of view, that is acceptable, but layering in a cost-benefit analysis adds a more objective way of deciding whether the care delivered is “worth the cost,” Dr. Wachter said.

The reform bill, to my mind, mostly kicked the hard decision for cost, quality, and safety down the road.

—Bob Wachter, MD, MHM, chief of the hospitalist division, professor, and associate chair of the Department of Medicine at the University of California at San Francisco

“The question is: Where do we want to live on this curve?” he added. “As you spend more money, you may be getting more benefit, but the incremental amount . . . pushes out past the flat part of curve.”

Dr. Wachter boiled his lesson down to two philosophies. In one, the practice of HM means a test, a procedure, or a consult is ordered because the benefits outweigh the risks. In the other, that same episodic treatment is ordered only if every less-expensive option has already been attempted. “These are absolutely fundamental tensions,” he admitted.

But not all that is reform must be contentious, he said. Take the renewed push toward “accountable-care organizations,” in which providers partner and share responsibility for both the quality and cost of healthcare for a specific population of beneficiaries. The healthcare reform bill contains incentives for such a structure, which Dr. Wachter views as the government’s latest attempt to improve care by controlling how much reimbursement physicians and their employers receive.

While other specialists might not be experienced with data-point discussions on cost savings with hospital administrators, HM leaders are all too familiar with the concept, as most have those discussions during annual hospital subsidy negotiations. Correspondingly, those who listened to Dr. Wachter’s advice agreed that there is ample opportunity to lead the charge for quality and safety improvement—and the likely savings to be associated with those changes.

“Let’s be patient for what’s coming around the corner,” said Daniel Dressler, MD, SFHM, director of hospital medicine at Emory University Hospital in Atlanta and an SHM board member. “But let’s not miss the boat.” HM2010

Richard Quinn is a freelance writer based in New Jersey.

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