Healthcare Efficiency

Community Health Centers (CHC) are wonderful places.  Marvels of efficiency, they deliver comprehensive primary care to underprivileged and frequently unappreciative patients at costs below any similar system of care.  They have to.  They have a dreadful payer mix, with large numbers of uninsured and almost no private pay patients.  The Commonwealth Fund, which champions similar issues, recently cited a study in which CHCs were used as a laboratory to study interventions for three chronic diseases:  hypertension, asthma, and diabetes.  Chronic diseases have been described as the millstone that may sink healthcare initiatives being floated by various politicians, so any improvement in efficiency would be welcome news.  

And the answer is, yes.  At least for diabetes and asthma, holding pep rallies at the CHC did improve the “quality” of care.  Here, “quality” was defined as conformance to prescribed standards  (foot exams for diabetics, etc.).  Gains were small, about 5% improvement.  And the bad news is that it didn’t make any difference in the cost of caring for patients with these conditions.  They had the same number of ER visits and hospital admissions.  How come?  It should have worked?  Several possibilities:

1. It takes time.  This was a short term look at an intervention that  will take years to bear fruit.

2. The gains were too small to produce any visible impact.  It’s also not clear what the start and end points were.  Moving from 75% to 80% conformance isn’t likely to do much for outcomes.

3. We’re wrong.  Doing foot exams for diabetic patients, etc. really doesn’t improve their disease process enough to show any decrease in future healthcare needs.  Time to look at basic assumptions.

Studies like this have implications for Pay for Performance programs.  If we’re going to pay providers to conform to our concepts of “quality,” we should anticipate some economic payback.  Show me the money.

Posted by Dr. Robert Burney at 08:54 AM | Permalink | Comments (0)

Yes, Rose.  You put your finger on two key problems with healthcare in the US today:  it’s expensive, and not everyone has access.  Malpractice is a phony issue--not a statistically important component of cost.    And yes, we do have the best healthcare in the world (at least from a technical standpoint), but remember that “healthcare” is not related to infant mortality, longevity, etc.  Those are social and environmental issues, more related to the number of coal fired power plants than the quality of healthcare.
I believe in the power of free markets and strongly support competition among healthcare providers.  “Managed competition” smacks of central planning and is probably a bad idea--especially since I think I heard George utter that phrase once.  Its nice to have a president like that, because anything he’s for, you can be against without even thinking about it.

The point of the P & T article and book cited previously is that competition in healthcare is currently misplaced.  It should be between providers over price, rather than  at the plan level over patients.

Meeting NCQA (for HMOs) or JCAHO (for providers) standards is good but not enough.  We’ve been doing that for years, and look where we are.  Technically good care is a given--or at least not a discretionary factor for patients.  Cost is becoming more important to consumers, but data are hard to find.  Call you local hospital and ask them what they would charge for an inguinal hernia repair.  (Then ask them to prove it by showing you the invoices for the last 10 patients they did.)  

Service quality is something consumers do understand.  My universal index of hospital quality is to walk into the ER and ask how long it takes to see a doctor.   Really good hospitals can tell you the average time for the last 30 days.  Many don’t know (Does this mean they don’t care?).  How long do you wait . . . for anything.  
Want to judge the quality of anesthesia services?  Ask for the average time from end of surgery to walking out the door in ambulatory surgery.  Remember, if they don’t know, it means they don’t care.  Anything above two hours is suspect.  Over three hours, go somewhere else.

And price.  We need price competition at the provider level.  There are lots of good surgeons and lots of good hospitals.  Now, lets talk cost. What’ll you do for me?  Ever wonder why Medicare doesn’t do this?

Posted by Dr. Robert Burney at 08:45 PM | Permalink | Comments (0)

Writing in the Washington Post yesterday, Martha Hamilton talks about the fear many prospective retirees havethat healthcare will become a significant financial burden--even with Medicare (M) coverage.  And, of course, woe unto anyone with the lack of foresight to retire before M eligibility kicks in.  Her index case did that and eventually paid $2,300 per month for healthcare insurance.  That’s more than most people pay per year!  

The point of the article, however was the threat of healthcare costs (not insurance costs) to retirees, even those on M.  For those eligible, about half of their costs are paid by M.  That can leave a significant amount to be paid out of retirement assets.  Even those with $1M in the bank are concerned that healthcare costs will adversely affect their retirement assets.  Compounding this problem is the fact that large companies are working to exclude healthcare benefits from retirees.  Of course, averages are deceiving, and it may be that M pays more when costs are higher.  In any case, the perception is that healthcare costs will loom large in later life.  As our population ages, more people will “join that inumerable throng,” and the solution will become ever more difficult and expensive.  

There are moral issues here.  It is popular to tax the rich, but should those who save be expected to pay for those who do not?  And what about personal habits?  Smoking, obesity, etc. take their toll only after many years.  

But those are personal choices, and society cannot legislate morality (or shouldn’t try).  I don’t remember prohibition, but I don't think it worked out well.  What we can do is ask people to be responsible for the choices they make. 

In any case, one fact is clear:  healthcare costs will be higher for anyone as age increases.  This is already true and will become more so as companies opt out of the health insurance business.  This must be factored in to any retirement plan.

As individuals, we can reduce our need through personal choices.  As a society, we can promote clean air and clean water--the two primary determinants of good health.  Those in health policy can reduce costs by introducing competition and price transparency at the level of individual healthcare services.  

As with most good things, these are not easy and they are not free.  But we do have a choice.

Posted by Dr. Robert Burney at 04:06 PM | Permalink | Comments (0)

The Commonwealth Fund recently released a brief comparison of several plans under consideration in Washington for changing health insurance.   The plans can broadly be divided into those that expand on existing government programs and those that expand on existing employer based plans.  In one sense, it’s the proverbial balloon--when you push down a cost here, it pops up somewhere else.  No free lunch in these plans.  For example, mandating the provision of health insurance by employers would reduce the number of uninsured.   But it would also reduce Medicaid and SCHIP rolls, thus shifting this cost to employers.  Similar concerns exist for other approaches, because the “uninsured” are not a homogeneous group.  Some are unemployed, but some are not.  Some are poor, but some are not.  Any plan that focuses on “the uninsured” will, like a Dick Cheney shotgun, strike unintended targets. 

Of course, no one wants to talk about costs, or more specifically, where the money will come from.  Buying health insurance for America’s uninsured is going to cost money.  Lots of money.  Several plans point to “administrative savings” and reference the low administrative costs for Medicare relative to private health insurance.  Now, someone will have to help me out here.  I work for the federal government, and they’re constantly talking about privatizing some or all of my office.  Now, you’re talking about de-privatizing the health insurance industry.  What am I missing?  Does anyone really believe that Medicare does it cheaper?  Or is this another urban legend?  One way to cut costs, of course, is to just not provide the service.  Ever try to  call Medicare?  (When you’re real bored, it's 1-800-MEDICARE.)  
One problem with all approaches to reforming health insurance is that they attack the wrong target.  It’s a worthy goal to help the uninsured, but a recent ASQ/Harris poll showed that most Americans are worried about the high cost of individual healthcare services, not the uninsured.  Yep, healthcare costs even edged out the Iraq war as a cause for concern.  None of the proposals under consideration will affect those costs.  Furthermore, all will increase the total amount of money spent on healthcare in this country. 

There is some suggestion that improving the efficiency of healthcare by focusing on cost of individual services could save enough money to finance healthcare for all the currently uninsured. 

It seems likely that something will be done to provide health insurance for some of the uninsured.  The debate will be on relative costs and who will pay.  No one realizes they could have it all for free.

Posted by Dr. Robert Burney at 03:45 PM | Permalink | Comments (0)