NEW @ THCB PRESS: Surviving Workplace Wellness. Spring 2014. Al Lewis and Vik Khanna. e-book edition. # INNOVATION: PCORI APP Challenge

Cost of Healthcare

Several years ago I had dinner with a woman who had served in the late 1990s as the national Chief Medical Officer of a major health plan. At the time, she said, she had developed a strategic initiative that called for abandoning the plan’s utilization review and medical management efforts, which had produced heartburn and a backlash among both physicians and patients. Instead, the idea was to retrospectively analyze utilization to identify unnecessary care.

This was at the height of anti-managed care fervor. A popular movie at the time, As Good As It Gets, cast Helen Hunt as the mother of a sick kid. When someone mentioned an HMO, Ms. Hunt’s character let fly a flurry of expletives. America’s theater audiences exploded in applause.

Apparently, the health plan’s senior management team bought into cutting back on medical management but saw no need for retrospective review. After all, if the health plan abandoned actions against inappropriate services, utilization and cost would explode. Fully insured health plans make a percentage of total expenditures, so more services, appropriate or not, meant the plan’s profits would increase.

And that’s how it played out. Virtually all health plans followed suit, dismantling the aggressive medical management that had been managed care’s core mechanism in driving appropriateness. In the years following 1998, health plan premium inflation grew significantly, for a short period reaching 5.5 times general inflation, but averaging 4 times general inflation through today. Medical management became all but a lost, or at least a scarce, discipline in American health care, which is its status now.
Continue reading “Why Medical Management Will Re-Emerge”

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The Medicare program is betting on a new course of action to curb what one medical journal has dubbed an “epidemic” of uncontrolled patient harm.

The effort is pegged to the success of a little-known entity called a “hospital engagement network” (HEN). In December, the government selected 26 HENs and charged them with preventing more than 60,000 deaths and 1.8 million injuries from so-called “hospital-acquired conditions” over the next three years. That would be the equivalent of eliminating all deaths from HIV/AIDS or homicide over the same period.

Despite those big numbers, and an initial price tag of $218 million, it’s unclear whether the HENs are adequately ambitious or still only pecking away at the patient safety problem. While this is by far the most comprehensive public or private patient safety effort ever attempted in this country, it still aims to eliminate less than half the documented, preventable patient harm.

The inspiration for these networks comes from similar collaborative projects run by the Institute for Healthcare Improvement and other groups. Dr. Donald Berwick, IHI’s founder and president, headed up the Centers for Medicare & Medicaid Services for two years and launched a larger Partnership for Patients that includes the HENs.

In December, the government chose a mix of national and local groups — primarily health systems and hospital organizations — to run individual HENs. Each HEN is charged with spreading safety-improvement innovations that have been proven to work in leading hospitals to others through intensive training programs and technical assistance. Although the program lasts three years, initial HEN contracts are for two years, with an “option year” dependent upon performance.

Continue reading “Is a New Federal Patient Safety Effort Doing Enough to Curb Medical Errors?”

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We’ve long argued this meme isn’t true. But now it’s explicitly false:

Last year, about 80,000 emergency-room patients at hospitals owned by HCA, the nation’s largest for-profit hospital chain, left without treatment after being told they would have to first pay $150 because they did not have a true emergency.

Led by the Nashville-based HCA, a growing number of hospitals have implemented the pay-first policy in an effort to divert patients with routine illnesses from the ER after they undergo a federally required screening. At least half of all hospitals nationwide now charge upfront ER fees, said Rick Gundling, vice president of the Healthcare Financial Management Association, which represents health-care finance executives.

So sure you can get non-emergent care in an ED – if you pay for it out of pocket. Please understand I’m not saying that all care should be free. I’m saying that the emergency department is no different than a physician’s office. If you have insurance, or can pay for care yourself, you get it. Otherwise, you don’t. No matter where you are.

Why is this happening?
Continue reading “So Much For “Everyone Can Get Care In An Emergency Room””

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