As the President and Congressional leaders meet to discuss health care reform, the risks of stalemate are high. As a hospital leader and an academic who studies health care costs, we disagree about exactly why some hospitals cost more than others. But we agree on a lot: the U.S. health care system desperately needs re-engineering, we know enough to start the process, and Congress should act now.
The country faces two problems: costs and quality. At current rates of increase, health care will soon be unaffordable for all but the wealthy. Rising federal and state health care spending is the single largest factor in looming deficits.
On the quality front, recent advances offer tremendous promise, but it is difficult to translate best practices into daily patient care.
The research on variations has provided useful insights into the magnitude of the opportunity to improve our performance as a system. We must now explore turning those insights into actionable recommendations.
Whether one looks at individual physicians, hospitals, or regions, variations in both quality and costs are found. Some of the differences are explained by the socio-economic needs or preferences of patients, legitimate differences in prices, and the cost of teaching and charity care.
But hospital leaders and academics agree that important variations remain after accounting for all of these factors. Some of the variation is caused by providers who are giving more care than their patients need. This is bad for patients and taxpayers.
We would point to three basic causes of unwarranted variation: limited information--about the risks and benefits of treatments and the quality of care; a fragmented delivery system with inadequate accountability for patients' care across providers and over time; and a payment system that often rewards more care rather than better care.
We therefore need better information that supports learning and improvement, organizational structures that support integration and accountability, and a transition to payment systems that reward better care.
But translating these principles into practice won't be easy.
Some ideas now on the table could make things worse. Proposed in one piece of legislation is a "value index" that would cut or raise fees to providers based on regional averages rather than their own performance and without taking into account good reasons for variation such as the severity of patient illness, poverty levels or the high cost of business in parts of the country. This would punish good providers in low-performing regions and reward bad providers in high performing regions. And it could cause some providers whose fees were cut to preserve their incomes by increasing the frequency of visits or the volume of profitable services.
There are, however, many good ideas that would support and reward providers' efforts to ensure that patients receive the right amount of care in settings that can reduce costs. For example, Accountable Care Organizations would allow physicians and hospitals to take responsibility for all of the care of defined populations - and be rewarded for improving both quality and costs.
Private payers and Medicare are already engaged in some small experiments to test these and other ideas. But it is not enough.
Congress should enact key provisions of the Senate and House bills related to measuring and improving quality and pilot testing delivery system reform, including the creation of the proposed Innovations Center that would enable the federal government to collaborate with health care providers and private payers to rapidly test, adapt and disseminate new payment and delivery models.
Academic medicine has a critical role. The leaders of academic medical centers have traditionally focused on advancing knowledge in the biosciences and improving clinical care. Now, some are stepping forward to learn from variations in practice and test new models of care. Congress should expand the mission of all academic centers to include not only the development of new treatments, but also the development of the much needed science of health care delivery.
With a sustained effort, we could solve our cost problems not by rationing, but by re-engineering care.
Herbert Pardes, MD
President and CEO, New York Presbyterian Hospital
Elliott S. Fisher, MD, MPH
Director for Population Health and Policy
The Dartmouth Institute
Principal Investigator, The Dartmouth Atlas Project
Insurance companies, doctors, hospital operators, pharmaceutical companies, armies of lobbyists, investors? It all adds up.
On top of that, we're not a very healthy country. Most of us do not have the proper nutrition and lifestyles. Obesity, diabetes, etc seem to be on the rise.
What a hot mess.
Single payer, IMO, would be a good step, but in a system where the pursuit of profits reigns supreme, whats the chance of that happening?
You only have one choice if you want to use the word 'solution'.
Get a clue, guys: We can't afford the profit taking paper pusher system of delivery any more. Fix that...then we can work on the other stuff.
Why people in this country insist on living in fantasyland and believe that you can take what we had left in precious taxpayer money, and instead of using it to rebuild a physical productive economy that provides tax revenue, we wasted it on bail outs, is beyond me.
1) CANCEL the bail outs FIRST
2) CANCEL the bankrupt HMO system
3) GO BACK TO A HILLS-BURTON STANDARD - hospitals/clinics 10-to-1 ratio doctors and nurses
4) SINGLE PAYER
"I mean, that's insurance. You buy it when you don't need it so that it will be there when you do need it. And if everybody waits until they need it to buy it, we result in the situation that we have today in the individual marketplace, where we have escalating insurance costs."
an insurance exec makes a great case for abolishing insurance.
Abortion is a choice, not a disease and should be eliminated from the bill. I don't believe in abortion, so why should I pay for somebody else's? If it is because of a health issue, then yes, but not as a choice.
I am guessing that one of the great challenges in getting to both demonstrated quality of care and better costs, in many people's minds, is not different from rationing, because they will look at an ineffective treatment that is removed from a choice set as an instance of rationing. Something they perhaps had access to in the past is suddenly not available will feel like rationing unless a trusted care provider can explain the science. And trust is the operative word, because when trying to manage cost, the temptation will always be to find a reason to not provide a particular treatment or course of care.
I believe that a vital part of the solution is to have separate bodies that evaluate efficacy from those that evaluate efficiency. So one body (presumably academic institutions) should ask does treatment A work better than treatment B and a different body should rectify the costs (perhaps the GAO or RAND). The findings should be consolidated and easily accessible, e.g. treatment X works 90% $100,000; treatment Y works 80% costs $1,000 per treatment. Given trusted data mechanisms, I think most people would respond correctly. This imaginary tool could also show how much personal incremental insurance premium there would be for treatment X and how much incremental premium there would be if all were insured for treatment X. This takes the emotionally charged word of "rationing" out of the political equation and replaces it with a direct sense of choice.