Sessions and Themes
- Shifting the paradigm: Vikas Saini
- Magical thinking and Modern medicine: Harvey Fineberg
- What makes us do it?
- What will it take to get us there?: Don Berwick
- What are the knowledge gaps in avoiding avoidable care?
- Case discussions
- What are the ethical issues?
- Medical journals and the issue of avoidable care
- The schizophrenic life of the hospital CEO
- A reason to change: Shannon Brownlee
- Social responsibility of physicians: Bernard Lown
- Behavior-changing Best practices
- Global dimensions of unnecessary care: Julio Frenk
- Payment mechanisms and the Culture of medicine
- Choosing wisely and beyond: What are the next steps?
- How can patients help drive the needed change?
Behavior-change best practices that work
HMOs–a bad word in health reform circles–flourished and then declined 20 years ago. But were they entirely worthless? Often they were bullies that took no patient or provider input into their decisions, and their cost control strategies could be brutal. Their payment schemes to providers could cause unscrupulous doctors to skimp on care, but they did bend the cost curve for a few years.
Their best feature was that their payment schemes did address overutilization. This had the potential to save lives and reduce morbidity. Nothing good can come to a patient who is subjected to a test or procedure that he doesn’t really need, and a great deal of risk comes with every medical intervention. I see countless instances of overutilization every day: repair of fractures that don’t really need it, shoulder and knee scopes for vague or non-existent indications, MRIs ordered for pain without any physical findings. Our current reimbursement schemes reward all of this.
If we knew then what we know now regarding patient satisfaction, physician strategies to improve patient outcomes, the importance of good communication and physician empathy, would the HMO payment model have had more success? Could we have kept patients satisfied, feeling well cared for, and been given good care while eliminating the financial incentives for dangerous overutilization? What if HMOs had understood the precepts of patient centered medicine as we currently understand it. Could primary care doctors have told their patients “no” without causing a backlash?
Now, I’m not suggesting that we return to HMOs, but alternative payment strategies that deliver just the care that patients really need can succeed so long as they are coupled with doctors practicing patient centered care. Office visits, especially to primary care docs, will need to be better reimbursed to make this model attractive to general practitioners, but HMOs floundered primarily due to poor patient satisfaction rates, and we know enough now to manage costs better and keep our patients healthy and happy with their care.
Hi - I’m writing from the Yale Global Conference on Health. The questions of the survey reflect a lack of studying how other advanced countries have learned to control the rise in costs and services that zoomed in the 1960s, until the oil crisis recession of the 1970s. Why is there so much in-attention to how this problem of avoidable care as a SYMPTOM of mis-organization of financing and services? See my course on the answers: STANFORD 2011 Syllabus on Kaiser web:
In the US, Kaiser Permanente and a few other whole-system organizations have come up with similar solutions. Our own Veterans Health Administration showed how one can transform wasteful, 2nd-rate care into 1st-rate, efficient care in just ten years. Yet how they do this is not indicated in the choices offered for the survey questions.
In the area of prescribing, there is serious avoidable over-prescribing, which contributes to an epidemic of harmful side effects that cost even more to treat (often by prescribing yet another drug). See the INVERSE BENEFIT LAW on www.pharmamyths.net.
I guess I feel frustrated that most policy thinking about how to avoid unnecessary care and expenses today feels like discussions held in the US, Germany, and France in the early 1970s, after a series of articles at that time about excessive hospitalizations, investigations, operations, and prescriptions…
Daniel R. Hoefer, MD, Outpatient Palliative Care and Hospice, Sharp HospiceCare
The vast majority of healthcare is paid for by a model called fee for service. The physician is paid once a procedure or event occurs. This became the foundation for Medicare reimbursement. At Medicare’s inception this was an acceptable model. Life expectancy was about 68 on average and the cost of care was limited by knowledge and relatively few available services.
Fifty years later however, technology and knowledge have dramatically increased. Unfortunately the culture of care and management of the elderly has not kept pace. (This includes the culture of reimbursement.) The fastest growing segments of the US population are over age 70 – 80. Yet, research historically deliberately excluded these demographics. We now know that the psychosocial needs of patients and families, goals of care and human physiology change as people live longer: http://www.nxtbook.com/nxtbooks/nhpco/newsline_201204/#/0.
We furthermore know that originally we had a reactive model of care, both medical and psychosocial. However, when 90% of patients in this country die from the predictable end stages of chronic illness a reactive model achieves inferior results. The hospital unnecessarily becomes a tool to manage late-stage disease.
Since 2007 Sharp Health Care through Sharp HospiceCare has embraced these changes. They have developed a model of transitional care which provides concurrent traditional and palliative management. Patients have complete access to traditionally aggressive treatment strategies but as their disease progresses can participate in aggressive palliative and then aggressive hospice strategies. The course of treatment is guided by the goals of care of the patient, including the fact that most persons do not want to be institutionalized and prefer to stay at home.
By providing a concurrent model of care patients have better quality of life, and their goals of care are respected at decreased cost. Hospitalizations are dramatically decreased. Caregiver and families as well have better outcomes. Sharp HospiceCare is decreasing the cost curve of healthcare, not by decreasing care but by dramatically improving the way it is delivered.