The good news about being a wishy-washy centrist like me is that unlike Napoleon I never have to worry about whether my left flank is covered, as Don McCanne does it for me. Today he found this letter in an Alberta newspaper which shows that using new organizational techniques the waiting time for hip replacement in Alberta was cut from 47 weeks to 4.7. It’s worth reading the letter that details this, as it also shows that numerous lies continue to be told about health care in Canada by the ideologues up there and down here.
But the key point is that public as well as private sector organizations can make the organizational changes necessary to improve productivity — in this case each surgeon has apparently doubled the number of operations they perform. While the details about how it happened are limited, as are hints on the extra money it cost, it is clear that there was no increase in the amount of most expensive resource — the surgeon. After all it takes a few decades to get a new one out of the shoot and the Canadians sensibly limit the number that they produce. Something Americans don’t see the need to bother with, despite the havoc it wreaks.
Of course whatever your system of payment or the organizational form of your providers, you are going to be able to make improvements in the way care is delivered. But that’s not the case if your insurance system is as screwed up as ours is, and the real innovation comes in how to avoid insuring anyone under-65 who needs the care, or how to “persuade” the government to make sure that its over-65 insurees get all the care they need — and much, much more.
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Eric–from a study in your home state last year in Health Affairs I believe (but iy’s midnignt and I’m going to bed)
Matthew- I am very interested in the data for ‘total costs go up’. Very interesting if true…
Quickly, as I’m on another deadline…
Eric, I love doctors, and I’m directly responsible for the nice life style of several Bay Area knee surgeons…don’t get churlish!
The surgeon is the most expensive resource because if there were no surgeon there would be no surgery…therefore all the other costs can be constrained by limiting the amount of surgeons. Plus it costs lots and lots of public money to train a surgeon (including in this country).
I am all in favor of specialty teams, specialty hospitals, clown shows or anything else that improves care and reduces costs. But I want that cost to be spread across a population, not be an add-on to money already being spent as has often been the case with specialty hospitals here. When pre-paid systems like Kaiser Permanente or Canada decide that the numbers work well enough to introduce specialty hospitals, then I’ll believe it. But up to now in the US it’s impossible to disentagle the data from either the self-referral effect, the added surgeries, or the added costs dumped on the system (in that the costs at the specialty hospital are greater than the total reduction in costs at the community hopsital, so total costs go up).
Specialty teams are an interesting concept that may even have some merit as a separate discussion. As I recall in the mid 90’s there was talk about these “teams” being a way to save significant dollars by reducing overlap and aligning provider/patient goals.
My understanding of how the these teams would save dollars is that in the case of a total knee replacement, there would be 1 payment for the whole process start to finish. All of the players on the team would be paid accordingly, the care would be aligned and hopefully the outcomes would be improved.
The challenge would be that patients would lose some choice in picking the various providers and that smaller independent providers may be left out of the process as larger groups and hospitals would be the groups able to provide this type of care initially.
Love the dialogue…..
Would love to maybe see a separate discussion on the possible merit of these teams at some point.
Matthew- looking forward to your rebuttal. Another point can be made that whatever can be gleaned from this letter (and it is not really very much) would argue in favor of specialty hospitals and against community hospitals— specialized teams taking care of specific kinds of patients with particullar problems seem to be part of the way that the ‘increases in efficiency’ were made.
Crap. I rebutted all your points and Firefox somehow closed the effing window. Effing annoying crap Microsoft keyboard settings that you can’t turn off drive me effing mad. Something to do with hitting ALT and somehting but In dont know what.
Will rebutt you some other time
Dr. Novack makes some great points, but particularly when it comes to #6. As a Physical Therapist, I have seen many EOB’s after total joint arthroplasty (hip, knee, shoulder with the occasional ankle) and I can attest that the reimbursement from Medicare is roughly $1200 to $1600 per case. The bulk of the EOB is typically reflective of implant and hospital costs and then you really see the numbers rise.
Now if we break it down to hourly pay for the orthopod, to come in, change, scrub, do the surgery and the follow up the pay is not worth it from a strictly “business” perspective. Heck, the WSJ this week noted that the average Roto-Rooter bill for clearing a clogged sink is over $200?!?!? Ask any MD, regardless of specialty if their profession is the best profession to get rich and you will hear a resounding NO. Most of these folks really care (not allof them as we all know some that do not) and really do enrich the lives of others to the best of their abilities.
Matthew does state that his “key point is that public as well as private sector organizations can make the organizational changes necessary to improve productivity” and with that I agree. However, I would have to say that through the use of a more open market incentive based system the changes come quicker and often easier.
Matthew- please cut back on the egg nog- the holiday is over!
There is too much here to go through- but let me start:
1. Limit the number of doctors — less than 700 orthopedic surgeons begin training each year. The dsitribution may be a problem, but certainly large areas of this problem do not believe there is an oversupply (or would you have a national organization determine where doctors can practice?)
2. More transparency would help reduce the practice variations by location (relying on a study published in 1986 is kinda weak…)
3. As you said- you have no idea what it took to get the reduction in wait times. The only hint in the letter is that INCREASED SPECIALIZATION occurred (specialized surgical teams).
4. You have no independent corroboration of anything in your post that shows where the source data comes from…
5. Wait times and for profit vs non profit are not necessarily connected (don’t you make that case in the blog regularly?)
6. THE SURGEON IS USUALLY THE LEAST EXPENSIVE ITEM ON THE BILL! Just ask to see an EOB from anyone who has had one. Medicare pays approx $1400 for the operation + 90 days of follow-up, plus indefinite liability. Implant costs, OR costs, hospital costs, rehabilitation costs are generally all higher than surgeon reimbursement.
Your ‘hate the doctors’ rhetoric is not generally agreed to by your readers, as the response to my Medicare post implies (despite your less than complimentary introduction…)