In 2006, Governor Mitt Romney signed Chapter 58 of the Acts of 2006 entitled “An Act Providing Access to Affordable, Quality, Accountable Health Care.” It has been described by many names, including Massachusetts Healthcare Reform (MHR), Romneycare, or simply, as the template for the Affordable Care Act. The goal of the act was straightforward: to ensure near-universal access to health insurance for citizens of the Commonwealth of Massachusetts. The bill quickly led to insurance expansion: by 2010, 94.2% of adults under 65 had health insurance, an 8 percent increase over the 86.6% in 2006. By all accounts, the goals of insurance expansion were met.
But the bill has not been without controversy. There have been two main concerns: first, that the bill did too little to control rising healthcare costs. The cost crisis led to the 2012 bill that many refer to as “Mass Health Reform 2.0” – formally called Chapter 224 of the Acts of 2012. Its focus is to curtail healthcare spending, and while reasonable people have reasons for skepticism about the likelihood of success, that’s a topic for another day.
Should we hold hospitals accountable for what happens after a patient leaves the hospitals’ doors? A year ago, I thought the answer was no. A hospital’s job was to take care of sick patients, make them better and send them on their way. With more thought and consideration, I have come to conclude that I was probably wrong. It may be perfectly reasonable to hold hospitals accountable for care beyond their walls, but we should be clear why we’re doing it. Readmissions are not a good quality measure – but they may be a very good way to change the notion of accountability within the healthcare delivery system.
The debate around the readmissions measure has come to the forefront because of the CMS Hospital Readmission Reduction Program, which penalizes hospitals for “greater than expected” readmission rates. It has raised the question — does a hospital’s 30-day readmission rate measure the “quality of care” it provides? Over the last three years, the evidence has come in, and to my read, it is unequivocal. By most standards, the readmissions metric fails as a quality measure.
Why do I say that readmissions are a poor measure of hospital quality? First, we have to begin by thinking about what makes a good quality measure. Quality is about the essence of the thing being produced – a good or a service. The job of a car is to get you from place A to place B and a high-quality car may be one that does the job reliably, safely, or maybe even comfortably. The job of a restaurant is to provide a meal that you don’t have to cook — and a high quality restaurant may provide food that is fresh, tasty, or with an attention to service that you enjoy. What is the job of a hospital? When you get sick and require hospital services, a high-quality hospital should give you the right treatments, attend to your needs while you’re there, and make sure nothing bad (i.e. a new nosocomial infection) happens along the way. That’s how we measure hospital quality.
Quality measures for healthcare come in three flavors – structural measures (do you have enough intensivists manning your ICU?), processes measures (did you give the heart attack patient his or her aspirin?) and outcomes measures (did the pneumonia patient die?). The elemental part of both structural measures and process measures is that they have to be tied to an outcome we care about. If having more intensivists in the ICU does not lead to lower ICU mortality (or lower complication rates), we wouldn’t think it’s a particularly good quality measure. We know that giving aspirin to heart attack patients lowers their chances of dying by 25%. We have multiple randomized trials. We don’t need much more evidence. Hospitals that have the right structures in place and reliably deliver the right treatments can reasonably be called high-quality hospitals.
Over the past decade, there has been yet another debate about whether pay-for-performance, the notion that the amount you get paid is tied to some measure of how you perform, “works” or not. It’s a silly debate, with proponents pointing to the logic that “you get what you pay for” and critics arguing that the evidence is not very encouraging. Both sides are right.
In really simple terms, pay-for-performance, or P4P, can be thought about in two buckets: the “pay” part (how much money is at stake) and the “performance” part (what are we paying for?). So, in this light, the proponents of P4P are right: you get what you pay for. The U.S. healthcare system has had a grand experiment with P4P: we currently pay based on volume of care and guess what? We get a lot of volume. Or, thinking about those two buckets, the current fee-for-service structure puts essentially 100% of the payments at risk (pay) and the performance part is simple: how much stuff can you do? When you put 100% of payments at risk and the performance measure is “stuff”, we end up with a healthcare system that does a tremendous amount of stuff to patients, whether they need it or not.
Against these incentives, new P4P programs have come in to alter the landscape. They suggest putting as much as 1% (though functionally much less than that) on a series of process measures. So, in this new world, 99%+ of the incentives are to do “stuff” to patients and a little less than 1% of the incentives are focused on adherence to “evidence-based care” (though the measures are often not very evidence-based, but let’s not get caught up in trivial details). There are other efforts that are even weaker. None of them seem to be working and the critics of P4P have seized on their failure, calling the entire approach of tying incentives to performance misguided.
The debate has been heightened by the new national “value-based purchasing” program that Congress authorized as part of the Affordable Care Act. Based on the best of intentions, Congress asked Medicare to run a program where 1% of a hospital’s payments (rising to 2% over several years) is tied to a series of process measures, patient experience measures, and eventually, mortality rates and efficiency measures. We tried a version of this for six years (the Premier Hospital Quality Incentives Demonstration) and it didn’t work. We will try again, with modest tweaks and changes. I really hope it improves patient outcomes, though one can understand why the skeptics aren’t convinced.Continue reading…
Healthcare: The Journal of Delivery Science and Innovation, a new journal promoting cutting edge research on innovation in health care delivery, has launched. The questions is, do we really need yet another journal? The short answer is yes. The longer answer is, absolutely yes. Here’s why.
The Need for New Knowledge on Healthcare Delivery
There is an urgent need to improve our mess of a health care system. Healthcare will consume about $2.8 trillion in 2012 – that’s an astronomical amount of money. To think of it in another way: spending in Intensive Care Units will make up 1% of all economic activity in the U.S. In a broader context, about 1 in 5 dollars in the economy will be spent on healthcare.
How will we actually spend the $2.8 trillion? Over a million doctors and nurses will see patients in hundreds of thousands of clinics, hospitals, nursing homes, and countless other settings. They will see patients who are sick and suffering and will make decisions about how to help them get better. These intensely personal decisions will be made in the context of a broader healthcare delivery system that is mindboggling diverse, complex, and fundamentally broken. We are probably wasting more on healthcare than we are spending on education. Yet, despite all this money and excess (or may be because of it), tens of thousands of Americans are dying each year because of poor quality, unsafe care. We can do so much better.
I’ve been getting emails about the NY Times piece and my quotation that the penalties for readmissions are “crazy”. Its worth thinking about why the ACA gets hospital penalties on readmissions wrong, what we might do to fix it – and where our priorities should be.
A year ago, on a Saturday morning, I saw Mr. “Johnson” who was in the hospital with a pneumonia. He was still breathing hard but tried to convince me that he was “better” and ready to go home. I looked at his oxygenation level, which was borderline, and suggested he needed another couple of days in the hospital. He looked crestfallen. After a little prodding, he told me why he was anxious to go home: his son, who had been serving in the Army in Afghanistan, was visiting for the weekend. He hadn’t seen his son in a year and probably wouldn’t again for another year. Mr. Johnson wanted to spend the weekend with his kid.
I remember sitting at his bedside, worrying that if we sent him home, there was a good chance he would need to come back. Despite my worries, I knew I needed to do what was right by him. I made clear that although he was not ready to go home, I was willing to send him home if we could make a deal. He would have to call me multiple times over the weekend and be seen by someone on Monday. Because it was Saturday, it was hard to arrange all the services he needed, but I got him a tank of oxygen to go home with, changed his antibiotics so he could be on an oral regimen (as opposed to IV) and arranged a Monday morning follow-up. I also gave him my cell number and told him to call me regularly.
Currently, India spends about $20 per person per year on healthcare and spending more once seemed like a peripheral concern, taking a back seat to basics like food and sanitation. However, in the past decade, as the Indian economy has grown and wealth followed, Indians are increasingly demanding access to “high quality” healthcare. But what does “high quality” mean for a country where a large proportion of the population still goes hungry? Where access to sanitation is so spotty that the Supreme Court recently had to decree that every school should have a toilet? What is “high quality” in a setting where so many basics have not been met?
It turns out that “high quality” may mean quite a lot, especially for the poor. A few weeks ago I spent time in Delhi, meeting with the leadership of the Indian health ministry. I talked to directors of new public medical schools and hospitals opening up around the country and I met with clinicians and healthcare administrators at both private and public hospitals. An agenda focused on quality rang true with them in a way that surprised me.
The broad consensus among global health policy experts is that countries like India should focus on improving “access” to healthcare while high income countries can afford to focus on the “quality” of that care. The argument goes that when the population doesn’t have access to basic healthcare, you don’t have the luxury to focus on quality. This distinction between access and quality never made sense to me. When I was a kid in Madhubani, a small town in in the poor state of Bihar, I remember the widespread impressions of our community hospital. It was a state-run institution that my uncle, a physician, once described as a place where “you dare not go, because no one comes out alive”.
A few months back, we admitted a patient we’ll call Mr. Jones to the hospital for a severe gastrointestinal bleed. We had discharged him two weeks earlier after he had come in with a heart attack and made sure he was on aspirin to prevent future cardiac events. He dutifully took his aspirin and on the day of the readmission, had a massive bleed. He made it to the hospital barely alive and an endoscopy in the ICU showed an active bleeding gastric ulcer. For Mr. Jones, the gastrointestinal bleed, likely brought on by the aspirin, was an “unintended consequence” that almost killed him. Yet no one questioned whether we should have given him aspirin in the first place. I felt terrible about what had happened but found solace in knowing that while for some patients the risks of aspirin are worse than the benefits, for the general population of people like Mr. Jones, the benefits are clearly worth the side-effects.
We do risk-benefit analyses every day in clinical care, knowing that for some patients, the benefits will be outweighed by the harm. We try to be thoughtful about who might be hurt or not, but most of the time, we just can’t predict. So, when the benefits appear to outweigh the risks, we move forward and try to learn from cases like Mr. Jones.
While this kind of risk-benefit analysis is common in clinical practice, it’s unfortunately not how we discuss health policy interventions. No policy intervention is ever without risks, and it is rare that a new policy will have no side-effects at all. Yet, every time policymakers put in a new initiative, they sell it as a panacea. Critics, upon finding an unintended consequence, then declare the whole thing a failure.
An excellent example of this is health information technology, a topic that I have blogged about in the past. Proponents only talk about its benefits, allowing critics to highlight every shortcoming and failure. Thank goodness I don’t have to deal with proponents and critics like that every time I consider prescribing aspirin to my patients.
The wrong question always produces an irrelevant answer, no matter how well-crafted that answer might be. Unfortunately the debate on health information technology seems to be increasingly focused on the wrong question. An Op-Ed in the Wall Street Journal argues that we have had a “Major Glitch” in the use of electronic health records (EHRs). This follows on a series of recent studies that have asked the question “do EHRs save money?” Or “do EHRs improve quality?” with mixed results.
While the detractors point to the systematic review from McMaster, boosters point to the comprehensive review published in Health Affairs that found that 92% of Health IT studies showed some clinical or financial benefit. The debate, and the lack of a clear answer, have led some to argue that the federal investment of nearly $30 billion for health IT isn’t worth it. The problem is that the WSJ piece, and the studies it points to, are asking the wrong question. The right question is: How do we ensure that EHRs help improve quality and reduce healthcare costs?
The fundamental issue is that our healthcare system is broken – our costs are too high and the quality is variable and often inadequate. Paper-based records are part of the problem, creating a system where prescriptions are illegible, the system offers no guidance or feedback to clinicians, and there is little ability to avoid duplication of tests because the results from prior tests are never available. Even more importantly, the paper-based world hampers improvement because it makes it hard to create a learning environment. I have met lots of skeptics of today’s health information technology systems but I have not yet met many physicians who say they prefer practicing using paper-based records.
The problem is that some Health IT boosters over-hyped EHRs. They argued that simply installing EHRs will transform healthcare, improve quality, save money, solve the national debt crisis, and bring about world peace. We are shocked to discover it hasn’t happened – and it won’t in the current healthcare system.
Late last week, thanks to Liz Kowalczyk (@globeLizK) of the Boston Globe, I discovered the statewide report on quality of stroke care in Massachusetts. It’s a plain document, mostly in black and white, much of what you might expect from a state government report. Yet, this 4-page document is a reminder of how we have come to accept mediocrity as the standard in our healthcare delivery system.
The report is about 1,082 men and women in Massachusetts unfortunate enough to have a stroke but lucky (or vigilant) enough to get to one of the 69 Massachusetts hospitals designated as Primary Stroke Service (PSS) in a timely fashion. Indeed, all these patients arrived within 2 hours of onset of symptoms and none had a contradiction to IV-tPA, a powerful “clot busting” drug that has been known to dramatically improve outcomes in patients with ischemic stroke, a condition in which a blood clot is cutting off blood supply to the brain. For many patient-ts, t-PA is the difference between living a highly functional life versus being debilitated and spending the rest of their lives in a nursing home. There are very few things we do in medicine where minutes count – and tPA for stroke is one of them.
So what does this report tell us? That during 2009-2010, patients who showed up to the ER in time to get this life-altering drug received in 83.3% of the time. Most of us who study “quality of care” look at that number and think – well, that’s pretty good. It surely could have been worse.
Pretty good? Could have been worse? Take a step back for a moment: if your parent or spouse was having a stroke (horrible clot lodged in brain, killing brain cells by the minute) – you recognized it right away, called 911, and got your loved one to a Primary Stroke Service hospital in a fabulously short period of time, are you happy with a 1 in 5 chance that they won’t get the one life-altering drug we know works? Only 1 in 5 chance that they might spend their life in a nursing home instead of coming home? Is “pretty good” good enough for your loved one?
Six months to the day after the Centers for Medicare and Medicaid Services (CMS) released the “preliminary rules” for Meaningful Use, the final rules are in. For clinicians and policymakers who want to see Electronic Health Records (EHRs) play a key role in driving improvements in the healthcare system, there’s a lot to like here.
For the Office of the National Coordinator (ONC), the agency that oversees the federal health information technology incentive program, the Meaningful Use rules are a balancing act. On one hand, ONC wants to get as many clinicians and hospitals on board with simply adopting EHRs (and thus, the need to set a low bar). On the other hand, they want to ensure that once people start using EHRs, they are using them in a “meaningful” way to drive improvements in care (and thus, the need to set a high bar). I think ONC got that balance just about right.
Let me begin with a little background. In 2009, Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act, setting aside about $30 billion for incentives for ambulatory care providers and acute-care hospitals to adopt and “meaningfully use” EHRs. Congress specified that the executive branch would define Meaningful Use (MU) and would do so in three stages. The first stage was finalized in 2010 and its goals were simple – start getting doctors and hospitals on board with the use of EHRs. By most metrics, stage 1 was quite successful. The proportion of doctors and hospitals using EHRs jumped in 2011, and all signs suggested continued progress in 2012. Through July 2012, approximately 117,000 eligible professionals and 3,600 hospitals have received some sort of incentive payment.