There’s a high-profile and important paper in JAMA this week by Sunil Eappen and colleagues. The study looked at surgical discharges during 2010 from a single 12-hospital system and came to the conclusion that admissions that include a surgical complication were associated with a higher profit (defined as the contribution margin) than admissions without complications. The authors conclude that this creates a disincentive for hospitals preventing surgical complications since they might see reduced profits as a result. This is a very provocative finding and it’s getting a lot of well-placed media attention, as you might expect. There is an important caveat with the study that I would like to highlight.
In the study, the authors report that admissions with surgical complications result in $39,000 higher “profits” if the care is reimbursed via a private payer and $1800 if Medicare is the payer. However, as Dr. Reinhardt correctly noted in the editorial,
“Allocating profit and loss is exquisitely sensitive to the many assumptions made in economic modeling and must be performed carefully to provide useful evidence about the financial ramifications of surgical complications and other services.“
His concern dealt mostly with how the authors allocated fixed costs in their calculations. My concern has to do with what the authors assumed happens to an empty bed once a patient is discharged in a US hospital.
Lost in the weeds of President Obama’s budget proposal is a 10-year, $11 billion reduction in Medicare funding for graduate medical education (GME). GME is the “residency” part of medical training, in which medical school graduates (newly minted MDs and DOs) spend 3-7 years learning the ropes of their specialties in teaching hospitals across the country.
Medicare currently spends almost $10 billion annually on GME. One-third of that is for “Direct Medical Education” (DME), which pays teaching hospitals so that they in turn can provide salaries and benefits to residents (current salaries average around $50,000/year, regardless of specialty; there are variances by region). No problem there.
The proposed cuts come from the Medicare portion known as “Indirect Medical Education” (IME) payments. Though IME accounts for two-thirds of the Medicare GME pie, it’s not easy for hospitals to itemize what exactly it is they provide for this significant amount of funding. Instead, hospitals bill Medicare based on a complex algorithm that includes the ‘resident-to-bed’ ratio, among other variables.
A 2009 Rand Corporation study commissioned by Medicare to evaluate aspects of residency training called on the government to tie IME payments directly to improvements in educational and hospital quality, lest the money be perceived to be going down a series of non-specific sinkholes. That idea has caught on, and legislators in both parties now see the healthy IME slice of Medicare education funding as a plum target for cost-cutting, as the direct benefits are difficult to enumerate, let alone quantify.
This has medical educators very worried that we will have to do more with much less (disclosure: I am one).
A few weeks ago, The Health Care Blog published a truly outstanding commentary by Jeff Goldsmith, on why practice redesign isn’t going to solve the primary care shortage. In the post, Goldsmith explains why a proposed model of high-volume primary care practice — having docs see even more patients per day, and grouping them in pods — is unlikely to be accepted by either tomorrow’s doctors or tomorrow’s boomer patients. He points out that we are replacing a generation of workaholic boomer PCPs with “Gen Y physicians with a revealed preference for 35-hour work weeks.” (Guilty as charged.) Goldsmith ends by predicting a “horrendous shortfall” of front-line clinicians in the next decade.
Now, not everyone believes that a shortfall of PCPs is a serious problem.
However, if you believe, as I do, that the most pressing health services problems to solve pertain to Medicare, then a shortfall of PCPs is a very serious problem indeed.
So serious that maybe it’s time to consider the unthinkable: encouraging clinicians to become Medicare PCPs by aligning the job with a 35 hour work week.
I can already hear all clinicians and readers older than myself harrumphing, but bear with me and let’s see if I can make a persuasive case for this.
Every day, millions of health care workers wake up and get ready to offer one of the noblest of services – to try and heal and bring comfort to the sick. They do valiant work, day in and day out, even as they confront extrinsic incentives that chip away at their mission and souls.
What are “extrinsic incentives?”
Consider this scenario. You’re driving a year-old car, and the engine light pops on. The car is under full warranty, so you bring it into the dealer. The problem is fixed quickly at no charge. This simple interaction between the buyer and provider of a service illustrates the broader and essential role of extrinsic (external) and intrinsic (internal) incentives.
Intrinsically, most of us want to do the right thing for ourselves, personally and professionally. You want to maintain the car well, so it retains its value and gets you safely from one place to another. The dealer wants to do the best possible job to keep you happy, so you’ll buy from him again. If the car is serviced well and doesn’t need extra repairs, he does well and so do you.
The Illinois hospital dinosaurs continue to defy evolution and prove that they are not extinct. I am talking about our health facilities planning board, which just turned down another Certificate of Need application for a new hospital, this time in the northwest suburbs of Chicago. The board justified the decision by stating that the new hospital would harm existing hospitals.
I know that the Chicago School of economics tells us that regulators serve the interests of those they regulate, usually at the expense of the public. But just because the Illinois planning board sits in Chicago, that doesn’t mean they have to slavishly follow the Chicago School. They could act in the public interest at least once in a while! (Though if the board started approving too many new health facilities, someone might notice that they are not needed and put them out of a job.)
Ensuring that Americans who live in rural areas have access to health care has always been a policy priority. In healthcare, where nearly every policy decision seems contentious and partisan, there has been widespread, bipartisan support for helping providers who work in rural areas. The hallmark of the policy effort has been the Critical Access Hospital (CAH) program– and new evidence from our latest paper in the Journal of the American Medical Association suggests that our approach needs rethinking. In our desire to help providers that care for Americans living in rural areas, we may have forgotten a key lesson: it’s not about access to care. It’s about access to high-quality care. And on that policy goal, we’re not doing a very good job.
A little background will be helpful. In the 1980s and 1990s, a large number of rural hospitals closed as the number of people living in rural areas declined and Medicare’s Prospective Payment System made it more difficult for some hospitals to manage their costs. A series of policy efforts culminated in Congress creating the Critical Access Hospital program as part of the Balanced Budget Act of 1997. The goals of the program were simple: provide cost-based reimbursement so that hospitals that were in isolated areas could become financially stable and provide “critical access” to the millions of Americans living in these areas. Congress created specific criteria to receive a CAH designation: hospitals had to have 25 or fewer acute-care beds and had to be at least 35 miles from the nearest facility (or 15 miles if one needed to cross mountains or rivers). By many accounts, the program was a “success” – rural hospital closures fell as many institutions joined the program. There was widespread consensus that the program had worked.
Despite this success, there were two important problems in the legislation, and the way it was executed, that laid the groundwork for the difficulties of today. Continue reading…
I am old enough to remember when physicians did not advertise. It was considered a professional ethical issue. Hospital advertising consisted of institutional “We’re here” ads. Anything aggressive by docs or hospitals was considered bad taste… but that was before health care became as competitive as any other type of business.
I have been barraged, as have many of you, by a wave of hospital advertisements as our health care marketplaces consolidate and organizations seek to brand and differentiate themselves. We are subjected to print, radio, and TV ads extolling services, expensive technology, and that fact that each institution cares more than its competitors.
Charlie Rohlfing blogged recently about the worst in hospital advertising techniques, and you will recognize them all. They usually include a Da Vinci Robot and orthopedic surgery that will “get you back in the game.” They claim to be “state-of-the-art,” “leading edge,” or “cutting edge,” with actors playing doctors and nurses in masks.
In the past, neither hospitals nor practicing physicians were accustomed to being measured and judged. Aside from periodic inspections by the Joint Commission (for which they had years of notice and on which failures were rare), hospitals did not publicly report their quality data, and payment was based on volume, not performance.
Physicians endured an orgy of judgment during their formative years – in high school, college, medical school, and in residency and fellowship. But then it stopped, or at least it used to. At the tender age of 29 and having passed “the boards,” I remember the feeling of relief knowing that my professional work would never again be subject to the judgment of others.
In the past few years, all of that has changed, as society has found our healthcare “product” wanting and determined that the best way to spark improvement is to measure us, to report the measures publicly, and to pay differentially based on these measures. The strategy is sound, even if the measures are often not.
This month the Agency for Healthcare Research and Quality (AHRQ) published a new report that identifies the most promising practices for improving patient safety in U.S. hospitals.
An update to the 2001 publication Making Health Care Safer: A Critical Analysis of Patient Safety Practices, the new report reflects just how much the science of safety has advanced.
A decade ago the science was immature; researchers posited quick fixes without fully appreciating the difficulty of challenging and changing accepted behaviors and beliefs.
Today, based on years of work by patient safety researchers—including many at Johns Hopkins—hospitals are able to implement evidence-based solutions to address the most pernicious causes of preventable patient harm. According to the report, here is a list of the top 10 patient safety interventions that hospitals should adopt now.
In 2004, I was managing a hospital division at the University of Chicago and our clinic director walked into my office and asked whether I thought that all physicians should be issued with smartphones. My first internal thought was, “Hmm, what’s a smartphone?”
Today, we all know how dramatically different mobile phones are than they were a year or two ago, much less back in 2004. But as the power of mobile technology increases, tech entrepreneurs have taken a lead on challenging old rules that haven’t been discussed in decades. What if the development of the smartphone could give us some clues into the future of healthcare IT?
Recently, I was on a business trip to Boston and met a friend for dinner. As we discussed where to go, I wanted to go someplace close, thinking that getting a taxi would be a pain. My friend pulled out his smartphone and requested a car to pick us up through the car-sharing service Uber. If you haven’t heard of Uber, or Sidecar, or Lyft, the essence is that the headache, the wait, and sometimes the expense of getting a taxi are virtually eliminated.