What’s Next?
Two days after the election, the Institute for Health Improvement (Don Berwick’s old outfit) held a conference to discuss where the health system goes from here. Among the 100 invitees were former Senate majority leaders Tom Daschle and Bill Frist, so you know it was pretty high-powered.
In the write-up of the conference the sense of both urgency and opportunity was palpable. (You can get a copy by going to Berwick’s Health Affairs blog post on it and then following the links and registering with IHI.) But the discussion is also disturbing and sobering.
There isn’t much question that the participants are hands-on experts at running hospitals, physician groups, health plans and the like. They know the ropes. They know the challenges. But, still, they are allowing fine rhetoric and political optimism (read “hope and change”) to blind them to reality.
First, they seem quite relieved the election turned out the way it did. The “tremendous confusion, even trepidation” is over, and the page has been turned. The report says the participants “predicted with startling unanimity that time is running out to save American health care from blunt cost cutting that would put the health of patients at risk.”
They also fully expect “significant cuts to reimbursement” in the very near future, but seem to welcome the cuts as a way to force better coordination of care and they believe physicians are now more willing to “collaborate” with management, especially on the dual goals of bundled payments and transparency. And here is the first contradiction.
No one seemed to consider that bundled payments and transparency actually work against each other. I won’t quite say they are mutually exclusive, but getting close. Transparency is relatively easy in a fee-for-service setting — we did X and got paid Y. It is relatively easy to see how the patient responded to the particular treatment.
But a transparent bundled package of services would require knowledge of what was in the bundle and whether the bundle was appropriate for the patient’s needs. It is hard to look inside the bundle to determine if every discrete element was delivered competently (or at all) by a qualified professional. “Bundling,” while not a bad idea in itself, raises a host of questions.
Will every group use the same bundle? How can a payer tell that the bundle in Facility X is the same as the bundle in Facility Y. If not, should the payment be the same for both bundles? What if there is something in the bundle that is inappropriate for a particular patient or group of patients? Will it be delivered anyway? If not, who determines what to remove? Does that removal affect the payment? Can the bundle be quickly revised as more experience is gained or must a revision be approved by payers or the government? The process of bundling seems to hide information rather than expose it.
“Transparency” is similarly more complex than it would seem at first. Transparency of what and to whom? In what form will the newly transparent information be presented? How can transparency and privacy be reconciled? Are there liability protections for providers who are required to be more transparent?
Both “transparency” and “bundling” seem to have become some of those feel-good, catch-all phrases that mean very different things to different observers. Each of us assumes that they mean the same things to other people as they do to us. In that sense they are like “quality” — impossible to oppose, but also impossible to define.
None of this seems to have been discussed at the conference, but never mind, they rush on to other considerations, including a new “Grand Bargain” between the federal government and provider organizations.
The write-up explains it thusly −
- First, there will be cost cuts;
- Second, government will loosen regulations to give provider organizations more room to innovate on health care delivery in response to lower revenues;
- Third, to guard against foul play in a looser regulatory environment, providers will be required to be more transparent than ever before about the prices, processes, and outcomes of care.
The provider representatives spoke at length about the burden of regulations on their current practices and their ability to innovate. The regulators (in this case, Don Berwick and Tom Daschle) argued that providers’ bad behavior brought on the regulations. All hoped that greater transparency would do the trick.
But it is hard to see how. Transparency might help to reveal this bad behavior, but that would simply trigger regulatory intervention. Indeed, it is hard to imagine many regulators who would be content to simply punish bad behavior rather than preventing it from ever happening.
In any case, this “bargain” quickly devolved into a who-goes-first question. If innovation requires fewer regulations, will the regulators back off in the hope that these innovations will happen? Or will they insist on maintaining the regulations until the innovations are proven? I think I know that answer to that. And once again, “transparency” is being used as a talisman that really has no common meaning.
In any case, you get the drift. Curiously absent was any discussion of how patients feel about any of this. Yet it is the patient/taxpayer who ultimately pays for all of this and is the sole reason any of these people have a job in the first place.
And it is only the patient who can make change happen. The existing health care establishment is incapable of reforming itself. This establishment includes both the people providing the services and the people regulating them. Not one of them will admit that what they may be worthless. Each thinks that what THEY do is essential and they could do it better if only it weren’t for those other guys.
So, as the Titanic sinks into the frigid Atlantic, all the crew will be pointing fingers and blaming someone else for the disaster. I hope you have your own personal lifeboat ready.
I’m always weary when so-called state holders meet to discuss the direction they want the health care industry to follow. It’s rather have providers responding to patients acting as consumers using their own money determine the direct health care will follow.
“Second, government will loosen regulations to give provider organizations more room to innovate on health care delivery in response to lower revenues;”
This is a strategy that needs to be implemented in many other policy areas.
“more room to innovate”….scary
Earth to Berwick and his cronies:
Come see the reality of the changes you have wrought here in San Antonio at the “best” hospital system. I am watching the meltdown daily in the care of an elderly patient. Nursing care is atrocious. The hospital can’t get a urinalysis back in less than 2 hours and can’t get antibiotics on board with suspected sepsis and low blood pressure. Specialists are trying to control blood pressure and CHF, while hospitalists march in and stupdily declare it’s time to leave the hospital.
The hospital system lets nurses with advanced degrees go so it can save money by hiring those with ” 1 to 3 years’ experience.” A differnt nurse cares for the patient each day. There’s no conitnuity so the nurses don’t get bored. The hospital system keeping builiding bigger $$multimillion additions. Profits keep rolling in. Patients have a duty to die faster so administrators can keep getting their 7 figure salaries and the U.S. can stay globally competitive. I’ll skip our Harvard College 50th reunion so I don’t have to hear about what a great man in medicine Berwick is. And “bundling” is supposed to make all this bungling better?
Greg starts the new year off with his useful insightful analysis. You don’t have to agree with everything our hero says to agree that he focuses on the right issues.
His strong suit (now that he’s put the “Blue” one in moth balls) is questioning so much what is taken as gospel, including the latest buzzwords.
With respect to the referenced conference, it is perhaps significant that of the five P stakeholders, patients are rarely represented. The question then arises whom would you have represent those Ps? Most organizations that come to mind immediately favor government intervention. Would an HSA advocate be best? Maybe it’s time for a still another health-related association. Happy New Year
Jan Peter Ozga writes, “With respect to the referenced conference, it is perhaps significant that of the five P stakeholders, patients are rarely represented.”
In a top down managed (collectivist) organizational structure, the people (patients) are never represented. The ruling class (in this case the “stakeholders”) are elite in their knowledge and understanding of the problems, and are compelled by conscience to see after the needs of the masses of drones in the Great Unwashed.
Even as the intent here is cynicism, one wonders after the last election about the capabilities of people in the general public to think for themselves.
We are doomed–patiemts and doctors alike.
Those of us with sufficient experience and seniority can opt out of the madness to move to a private pay model; enough patients will follow to last us till retirement. The young docs presently training will all become chattel earning municipal bus driver salaries for working 9 to 5. And the public will get to know their new masters–the regulators and bureucrats who have hired the clinical nurse specialists to be our new primary care providers.
Hope everyone enjoys the ride.
I am not sure that a “bundle” means necessarily a particular list of items, procedures, and services that are “supposed” to be done, but rather a generalized concept of what “might” be done to achieve a given outcome (i.e., a knee replacement that incorporates all professional and facility services required, plus typical follow up, or whatever). Perhaps I am defining an “episode” rather than a “bundle,” but then Greg has correctly pointed out that the definitions of all these terms is quite fluid and hard to pin down. “I know what I mean, how come you don’t?” is often the attitude. For me, however, the concept of bundling, or episodic, or whatever combination packaging is contemplated, is still going to be evaluated on a “fee for service” basis at the end of the day: How many of these items did you actually use, or average, and at what average price per unit? That will allow for adjustment for ranges and outliers the next time around. However, all the “academic” questions Greg raises about how the elites want to debate the subject are very well developed. Perhaps it will give them something to do while the rest of us are, hopefully, allowed to solve the crisis in more practical ways.
“We evaluated the initial “road test” of PROMETHEUS Payment, one of several bundled payment pilot projects. The project has faced substantial implementation challenges, and none of the three pilot sites had executed contracts or made bundled payments as of May 2011. The pilots have taken longer to set up than expected, primarily because of the complexity of the payment model and the fact that it builds on the existing fee-for-service payment system and other complexities of health care. Participants continue to see promise and value in the bundled payment model, but the pilot results suggest that the desired benefits of this and other payment reforms may take time and considerable effort to materialize.”
http://content.healthaffairs.org/content/30/11/2116.abstract
Bundling will be difficult to set up.
This is all demand side “innovation”, maybe what we need is a physician rebellion, with the unique idea that the patient comes first. HSAs and HDHP for all Americans and these “experts” would finally be silenced. See our article in the Washington Times,
http://www.washingtontimes.com/news/2012/may/3/prudence-of-a-patient-centered-approach/
HD Carroll — Thanks. You may be right about the meaning of the word “bundle.” I really can’t tell. And the idea that bundling will somehow reduce health care costs baffles me entirely. Even if there might be some (very minor) efficiencies in packaging a group of services together, that should be a one-time saving without any effect on trend.
Somebody, PLEASE explain why this will reduce trend at all — let alone be the panacea the IHI people think.
Greg… bundling actually allows them to hide more costs in some cases
Government run health care is the ultimate bundle. Supply and demand are predeterimined in the big, fat, bundle offered to individual patients. They can take it or leave it but not affect its contents.
Vertical integration has the potential to reduce some of the externalities which drive up costs for consumers. But probably not. Linda and Ralph are right.