Many of you know that I have been writing (and some of you may have termed it “ranting”) about health care reform in America for several years. But, that’s because we have allowed ourselves to develop a system of reimbursement that is biased for testing and against outcomes. We also have a system that (in my humble opinion) provides an incentive to those lacking insurance to employ the services of a hospital emergency room.
We need to immediately stop the latter practice (I will discuss the former problem after this). A good many of these “emergency room incidents” involve illegal immigrants. (No, I will NOT use the politically correct, but factually inane, term “undocumented aliens”). There are also plenty of citizens, who either have no insurance or a doctor, who visit the emergency room for ailments best treated by physicians in their offices- or, at least, in urgent care centers. One only hopes the regulations being developed will provide some disincentive or financial penalty imposed upon these system abusers.
But, the real problem is our “fee-for-service” mentality. Our health care insurance pays for quantity (and quality be damned). [I won’t digress, at length, here to discuss the failure of insurance companies to afford patients the use of oral chemotherapy in lieu of intravenous- the former of which is better tolerated by patients, affords them the ability to keep working and be productive, has fewer side effects, but costs more money. Total benefits and cost analyses for America have no bearing here.] We need to develop a method that rewards desired outcomes. Even Medicare (and, now, the Veterans Administration) have determined that bundling services (pay a fixed amount for each health care problem; instead, they let caregivers/institutions determine the best way to deliver inclusive, quality care) is the only way to save money- and improve care- for dialysis. That is but one situation that would benefit from switching to outcomes-based medicine.
Let’s think about how our current system really works- and use a non-health care scenario to point out the paradox. When I contracted (and spent a fortune) to build a new kitchen/porch/patio, I did not agree to pay the contractor an hourly wage while he did his thing. Trust me, doing that only adds hours and costs to the bill. And, if things are done incorrectly, he/she gets paid more to fix them. (Now, there’s an incentive!) No, I agreed (???) to a fixed fee for the whole job- that’s called bundling. The contractor had an incentive to get the job done right the first time.
So, why not do this for medicine? Well, the government has tried this before—for bypass surgery in a demonstration project (as well as for dialysis). The results- shorter hospital stays, better survival, lower costs. And, what did we do…. N o t h i n g …….RAND has studied this concept for several areas in health care (including these two and health care information systems, and a few others) and determined this would reduce FIVE (5) percent of our health care expenditures. That is the savings we need- it counteracts the slow creep up of everything else.
In England, a new program is being developed to keep healthcare costs down. A hospital will be paid for its initial treatment of a patient- but NOT if the patient returns within 30 days with the same symptomology. This is an acknowledgement that hospitals have been discharging patients early to free up beds. (In America, that is encouraged by our health care insurers. I just watched a young girl have a defibrillator installed and then be discharged from the hospital way too quickly. Right after an older woman was discharged – in a virtually non-ambulatory state- with two temporary ureter drainage tubes (which did get clogged and infected over the next few weeks.)
There’s more though to this proposed English system. Instead of having the patient’s follow-up care under the auspices of their own doc (typically a GP, general practitioner), the hospital will be in charge (and part of its hospital compensation will include same) of the patient for the 30 days post-release. There’s an incentive and remuneration system that will make sense. We need to develop a system like that as part of our health care regulations, too!