Healthcare Efficiency

This is about efficiency, remember.  This discussion focuses on specialty hospitals, and in particular, an article by Stuart Guterman in Health Affairs, 25:95-106, 2006.  Many such have existed for some time, without controversy (childrens hospitals, psych hospitals, etc.).  The current reason for concern is over specialty hospitals that are owned by physicians and focus on procedures (orthopedics, surgery, cardiology, etc.).  These are opposed by general hospitals on the grounds that they cherry pick profitable cases and thus detract from hospital revenue.  These concerns were largely debunked by the Medicare Payment Advisory Commission, but Congress and CMS nevertheless imposed a moratorium on further licensing of Specialty Hospitals.  One additional concern is that physician-owners “will be torn between considerations of clinical appropriateness and financial benefit.”  This may be a problem with single owners of a facility, but personal experience in ambulatory surgery centers suggests the opposite when ownership is diluted.  “This isn’t the dressing I would prefer, but I know it’s cheaper, so I will use it.”  Amazing what a little profit motive will do to reduce costs of care.   
Just like ambulatory surgery centers, specialty hospitals represent change and are therefore opposed by all who benefit from the status quo (hospitals, universities, foundations, etc.).  Specialty hospitals probably represent a more efficient means of providing healthcare, and one would think they would be welcomed into the provider mix.  Even CMS concluded that “although specialty hospitals do not generally treat uninsured or Medicaid patients, the taxes they pay more than make up for that difference.”  Not wanting to be accused of rational thinking, CMS is now busy devising restrictions to further inhibit the development of specialty hospitals.  And healthcare costs continue to rise.  Gee, wonder why.

Posted by Dr. Robert Burney at 08:51 PM | Permalink | Comments (0)

Writing for the Commonwealth Fund, Karen Davis and Sara Collins discuss obfuscation in healthcare.  Want to know how much your appendectomy cost?  It’s really hard to tell.  Hospitals can take a year or more to assemble all the charges, and insurance companies don’t pay charges anyway.  Davis and Collins think more sunlight on costs could have positive effects.  Providers would have a benchmark, insurance companies would be able to “reward quality and efficiency” (no clues on what that means), and patients could make “informed choices.”  However, they go on to say that it wouldn’t really work, because “healthcare is not a homogeneous commodity” and “patients will never have as much information about the care they need as the physicians who care for them.”  Wow! talk about paternalism.  “You can’t understand these things, but trust me.  I’ll take care of you.”  Somehow, I don’t think so.  The same statements could be made about almost any purchase in this highly technical world.  Anyone know the compression ratio in their car?  Can you tell me the difference between a USB port and a firewire port on your computer?  But somehow, consumers manage to make choices about cars and computers.  Perhaps the same could be true in healthcare.  
In criticizing patient cost-sharing, they correctly point out that Americans already pay a larger share of healthcare cost than other countries.  Another study found that patients in high-deductible plans were less satisfied and more likely to forgo needed care than those with traditional insurance.  Well, duh!  They’re unhappy because they suddenly realize healthcare costs money.  Their money.  And who decides what care is “needed?”  They patients obviously decided it wasn’t, and their providers failed to convince them otherwise.  Funny how that works.  It’s called a free market, where consumers make choices--something heretofore absent in healthcare.  
Transparency is a chicken and egg thing.  Choice requires information, but no one will provide information unless patients have choice.  Today, we have neither.  Where do we start?

Posted by Dr. Robert Burney at 05:51 AM | Permalink | Comments (2)

Among the many emails waiting for me was  a note RE a recent publication in the Archives of Internal Medicine (not available unless you pay $).  Summary key findings:

1. 75% of primary care docs have problems obtaining patient info (test results, records, etc.) when they need them.  Many years ago, my daughter had open heart surgery at the Univ. of VA, and the surgeon ordered a chest xray on the way to the operating room.  He knew they could never find the one taken the day before, and it was simpler just to take another one.  Well, that is more efficient than delaying the OR, but . . . .

Key finding #2. Fewer than half send patients reminders about preventive or follow-up care.  My dentist does that!  Even the Goodyear dealer where I buy tires for my car sends notices when it's time to rebalance.  Guess these docs aren't hungry enough for the business.  Or maybe they aren't accustomed to accepting responsibility for their patient's care--a common feeling.  About five years ago, we instituted a monitoring program to evaluate our offices with respect to how  many women had had mammograms.  "That's not my job!" was a common response.  "We put notices on the bulletin board.  That's enough!"  On the other side is a friend who tells patients, "You can tell me 'no', but you can't ignore me.  I'll be back."

Finding #3.  Less than 25% use electronic medical records.   Note that both the above problems could be solved by EHRs.  Money is commonly cited, but I think it is mostly aversion to change.  The author (Audet A.J) thought doctors required "technical assistance."  Probably an age-related phenomenon, but doubt it is a major impediment. 

Posted by Dr. Robert Burney at 08:57 PM | Permalink | Comments (1)

"The notion that we can make health care so much more efficient that universal coverage can be financed without incfreasing outlays is a non-starter, in part,because stakeholders use the political process to protect their incomes, avoid price competition, and resist unfavorable regulation."  So says B. Bradison in "A Flixible Approach to Health Care Reform" for the Commonwealth Fund.  What he's saying is that those with the power to make healthcare more efficient don't want that to happen.  (I think I said the same thing a few paragraphs ago.)  To  paraphrase Machievelli, those who resist change the most are those who benefit most from the old system.  (See previous page for list of names.) 

Today, he is correct, but this is exactly the situation that has to change if healthcare costs are ever going to be controlled.   Healthcare today is not price competitive.  Patients rarely know or care what a given healthcare encounter will cost.  Is it any wonder then that costs continue to rise?  (Rhetorical question!)

Actually, the cost equation is fairly complex, and numerous factors are at work.  Chief among them is technology.  If you want the latest and greatest, it costs a little more.  Nevertheless, it patients were brought back into the marketplace, there would be pressure to contain prices.  Perhaps also charter flights to Bangkok. 

Posted by Dr. Robert Burney at 08:18 PM | Permalink | Comments (1)