Healthcare Efficiency

Pay for Performance (P4P)is the new poster child for curing healthcare.  The Institute of Medicine just released a report on this concept and concludes that if you pay people for doing something, they will, indeed, do it.  And even physicians are susceptible to this strategy.  This is not new to the quality world, but it is novel in healthcare.  The business equivalent would be supply chain management or supplier certification.  If you want to be a first tier supplier for company A, you must meet their tier one standards.  In healthcare, however, the AMA has long championed the concept of “any willing provider” and resisted attempts to exclude or limit any provider;s access to any market.  Their position paper on P4P reflects this bias and limits application of supplier management concepts to healthcare.

The IOM report does not mention cost of services or efficiency of either systems or individual services.  They do take a jab at fee-for-service payment (“...require a transformation away from fee-for-service payments....”), and argue that fee-for-service rewards excessive use of services.  It’s not clear, however, who gets to define “excessive” or how this leads to “lower quality care.”  Their argument seems intuitively true, but clear indications for surgery counteract this effect, as demonstrated, for example, with cataract surgery.
 
P4P is an important tool that will become more common.  The real trick is defining “performance” and recognizing that P4P will not solve all problems.  It will do nothing for cost, or efficiency, or access, or coordination of care.  It should not be expected to do so.  Use a hammer to pound the nail, then pick up a screwdriver.

Posted by Dr. Robert Burney at 07:42 PM | Permalink | Comments (2)

The Commonwealth Fund launched their scorecard for healthcare quality this week.  It seeks to be comprehensive by structuring its report on the six aims of the IOM.  With any report card, usefulness depends on credibility and use.  The measures must truly measure the parameter, and the reader must be able to take action to improve.  The CMWF uses multiple measures in each category and generally, these are relevant.   It was perhaps unwise to compute numerical scores, and they did so by comparing the average performance to the best performance.  The Tiger Woods analogy was discussed at length.  

True to their mission, they focused on the uninsured.  As mentioned here before, this is a political question and has nothing to do with healthcare.  There was also a lot of talk about costs of insurance--only remotely related to healthcare.  

We do agree that US healthcare scores poorly on efficiency.  They measure this by readmission rates and preventable hospital admissions.  However, they totally ignore the costs of individual healthcare services.   This is unfortunate, since this is the engine that could drive improvement everywhere in the system--the handle on the pump.  Price competition for healthcare services could drive down the costs of healthcare, making healthcare and health insurance affordable for all.

One interesting slide (#67) related cost to quality of care.  It’s a Dick Cheney chart--pellets everywhere.  Paying more doesn’t get better care, but I guess we already knew that.

Another issue emphasized is geographic and provider variability.  True, the first rule of quality is consistency.  Note, however, that reducing variation may improve “quality” but not necessarily efficiency.

It’s easy to throw darts at the charts.  However, this is an important effort and worth monitoring.  It’s equally important to look beyond the executive summary to see where the numbers come from. 

Posted by Dr. Robert Burney at 09:00 PM | Permalink | Comments (0)

Yes, John, we do miss some errors, but that will always be true.  The important point is that we haven’t done much to reduce the error rate, and the results are not impressive.  And yes, Nikki, education will be an essential ingredient if patients ever get the power to make their own healthcare decisions.  They will need to know how to make good decisions.  There are no magic pills for the most important determinants of health today--tobacco, obesity, and inactivity.  These personal choices are, however, amenable to education.  

An article in the Public Library of Science (and abstracted in the Washington Post) reported wide gaps in mortality between groups defined by race and geography.  Asian women live longest, and urban black shortest.  Although not surprising, there are several interesting conclusions from this article:  The disparities were minimal in infants--a tribute to federal programs directed at that age group.  Disparities were greatest in young and middle age adults, and the chief factors cited were tobacco and obesity, neither of which is related to healthcare.  The authors noted that there was little difference in health insurance, and access to healthcare was not a factor.  These conclusions highlight again the differences between health and healthcare.  As noted, health is related to genetic factors, personal choices, and environmental factors (clean air, water).  Healthcare is what you need when health fails.  The important point is that health can be measured by infant mortality, longevity, disease prevalence, etc.  These factors have little or nothing to do with healthcare.  It is thus unfair to criticize the healthcare system by citing infant mortality or life expectancy.   In fact, it may be argued that better healthcare actually negatively impacts health by preserving sick individuals in the population.  
So, what does the article have to do with healthcare efficiency?  Nothing.  And that’s the point.

Posted by Dr. Robert Burney at 09:02 AM | Permalink | Comments (1)

Karen Davis, et. al. report for the Commonwealth Fund on patient surveys in 2004 and 2005 on the IOM’s six criteria for healthcare quality.  Surveys were done in 5 countries, and showed that US patients thought highly of US healthcare with respect to “effectiveness” (a.k.a. the technical aspect of care) but ranked our system poorly (usually last) in the other dimensions.  This is not unexpected when you consider what the average patient has been hearing about the US healthcare system in the last few years: namely that we make lots of errors, screw things up in other ways whenever we can, and occasionally kill people.  
Well, we do have problems.  But I’m not convinced we are any worse than any other country you could name.  Remember now, these are patient opinions (and recollections), so they are likely to be influenced by the public face of US healthcare.  We need objective measures of the facts, rather than patient opinions.  One paper cited previously here measured medication errors in Canadian hospitals and found they were essentially identical to those in the US.  The CMWF paper mentions lab errors.  Folks in my office (State Department) evaluate laboratories in every country in the world, and we do use labs in some other countries, but on average, no one does it better.  
They also mention poor access to care for low income patients.  This, I think, is the wrong fruit.  Our system is based on private health insurance (ignoring Medicare/Medicaid for now), and health insurance is linked to employment.  You may bemoan the socio-economic system that fails to provide health insurance to low income Americans, but that is not the fault of the healthcare system.  Write your Congressman.  That’s a political problem.  To be fair, you have to compare people with the same health insurance but different incomes.  In that respect, I really don’t believe I get better healthcare than the man who empties my waste basket (and also has federal BC/BS insurance).

Posted by Dr. Robert Burney at 08:24 PM | Permalink | Comments (2)

The first rule of quality is consistency.  The antithesis, then, is variation.  Noon et. al. write about “The Impact of Variation in the Delivery of Healthcare Services” (publication not available) and note that variation in patient arrival time and variation in treatment time produce long waits and inefficient provider utilization.  [Anybody thinking walk-in clinics?]  In a comment on the article, Michael Lieb states that such long waits can generate “very negative responses from dissatisfied customers.”  Gee whiz!  He also comments that with procedures such as mammography, “patient expectations are easily met....”  (Where was he when GW needed him.)

In the same journal, Meyers et. al. describe the successful application of Open Access appointments in a military primary care clinic.  As they observe, this is counter-intuitive and certainly counter to the triage and wait approach in most ERs today.  With this approach, they asked patients, “Do you want an appointment today, and if not, when?”  When demand and capacity are balanced, all patients can be given same day appointments, thus eliminating the random arrival of patients.  The first paper demonstrated significant improvements in all variables when any variation was reduced.

Ambulatory surgery is an example of predictable arrivals for predictable service and should be intrinsically efficient.  The problem comes when hospitals run these centers and mix them with the general OR.  The variable of emergency surgery is then allowed to impact an otherwise efficient system.  
The take-away message is that efficiency is possible, even with seemingly random systems.  All it takes is the will to do it.  But that’s also true of so many things in life, like . . . weight loss.

Posted by Dr. Robert Burney at 08:20 PM | Permalink | Comments (0)