The Prescription for Revolutionary Healthcare Delivery Reform*

*Sorry, it’s not the Senate bill as far as I know. All that was known when this post was scheduled was: $849 billion to cover 94% of Americans, saving $127 billion over 10 years. That isn’t very informative in and of itself!

Hidden among the 1990 pages of HR 3962, there are some provisions to tinker around the edges of healthcare delivery and bend the cost curve to a minor extent. There are Medicare payment bundling and pay for performance pilot programs, comparative effectiveness research, and of course Medicare rate cuts. The combined Senate bill should have similar features. In truth, no one expects these strategies to have a big impact over the long term. As the photo translates, “Without theory, no revolution.” But what if we used the aggressive pursuit of four goals to revolutionize US healthcare delivery and bend the cost curve? A recent Health Affairs article explores what it would take to reach these far-reaching goals:

1. Improve the science of healthcare delivery

The US must prioritize developing a science of healthcare delivery, which is currently a black box. Patients with the same condition are treated in many different ways, depending upon the physician. Rarely does that physician do much research to determine what the most effective and cost-effective treatment might be. For example, many years ago I worked in two cardiac rehabilitation practices on opposite sides of town. The patients in each practice were on completely different blood pressure medications, depending upon which pharmaceutical reps visited which side of town! Less than 10% of the patients had their hypertension adequately controlled.

Electronic health records (EHRs) also aren’t typically deployed to help analyze the link between care and outcomes. They must support the incorporation of patient-reported health status and ongoing outcomes. I can tell you from long experience in EHR deployment that clinical decision support aids like these are “maybe some days” that are quickly forgotten once the EHR goes live. Focus shifts elsewhere. EHRs must be rolled out intelligently and progressively to enable safe, quality, scientific care.

2. Foster the expansion of organized systems of care

This goes back to the coordinated care model, where there is one accountable organization that coordinates comprehensive care to the patient for a bundled payment. Adhering to high-quality clinical processes, achieving high-quality outcomes, and providing a high-quality patient experience are rewarded with bonus payments (pay for performance.) This will rein in excess utilization – otherwise known as the quantity of care juggernaut – while improving the quality of care, especially for the chronically ill, who account for 60% of Medicare spending. It’s a model that will require a learning curve and frequent adaptation.

3. Establish informed patient choice as the standard for elective surgeries, tests, and procedures

The devil is in the details on this one. When they sign an informed consent, patients routinely don’t know what they are signing up for, and may not actually want what’s offered if they could actually understand it. This increases care costs and can lead to malpractice suits. Centers for Medicare and Medicaid Services (CMS) needs to develop standardized approaches to informing patients, not just obtaining their consent. States need to redraft their informed consent laws to focus on informed choice as the standard of practice. Finally, CMS needs to reimburse physicians for time spent on shared decision-making, reward high quality as in #2, and require hospitals and ambulatory surgery centers to support it if they wish to be Medicare and Medicaid providers.

4. Constrain undisciplined growth in healthcare capacity and spending

If we could slow Medicare spending growth by even 1% it would save $1 trillion over the next 15 years. Imagine the impact on healthcare spending as a whole. This goal relies on both carrots and sticks. The carrot is preferential treatment for superstars in #2 through pay for performance programs. The opposite also applies. Areas like McAllen, TX, where per capita spending has gone through the roof, are penalized. Even if only highest-cost hospitals are targeted, it might rein in out-of-control hospital construction (a record-breaking $50 billion worth in 2008) to more rational and population-based levels. Shrinking reimbursement in these areas would encourage more providers to transition to the coordinated care model with its quality-based performance incentives, or even just encourage hospital mergers to reduce unnecessary capacity.

Additionally, we don’t need more physicians generally; we need more primary care physicians. Specifically, we need more well-trained primary care physicians in under-served areas. Shifting residency slots to rural, understaffed, and the best teaching hospitals would fill that need. Finally, and of extreme importance, we need to fill in the big utilization cost black hole. For all the outrage over the Dartmouth Atlas Medicare spending findings, did you know there is no similar index for private health plans? That’s right: we have no idea of the overall healthcare spending patterns across the US. Just imagine the graft and waste going on under the radar. I’m betting there are a lot of cockroaches under them floorboards.

Photo srbyug // CC BY 2.0

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