Lola Butcher

I was lucky to interview Stuart Guterman, senior program director of the Medicare’s Future program at the Commonwealth Fund. A couple of things that caught my attention:

Lola: How should value in health care be measured, and do we need more measures or fewer?

Guterman:  That’s really the crucial issue. There has been a lot of discussion about paying for outcomes, and certainly one can make a strong case that how the patients survives the health care, what the health status of the patient is in the long run is really the bottom line. But I think we are where we are on being able to pay for quality because we’ve developed a set of more reliable process measures, that is measures of how services are provided that are expected to lead to better outcomes. So we now can put together a list of things that are pretty much accepted as ways health care should be provided that will lead to better outcomes.

In terms of more measures or fewer, there are arguments for fewer measures because a long list of measures is thought to present the prospect of confusion. I think that actually if you have a longer list of measures and if you really are comprehensive in the list of measures for what you pay for, then you’re really transmitting a broader message that the objective is to improve quality and improve the value that you get for the health care dollar.  I think that’s really the message that needs to be sent in value-based purchasing, not doctors should do this or doctors should do that. Doctors should really do a broad range of things that lead to better health for their patients.

Lola: How should providers be rewarded for value?

Guterman:  There are different ways to approach rewarding for value. Certainly you want to reward providers that provide the best care.  There have been studies that found, however, that if you rely only those kinds of measures, then you end up basically making most of your bonus payments to providers who already are at the level that you’re looking for.  If you’re really trying to improve the system, then you need to provide incentives for providers that aren’t where you’d like them to be to get where you’d like them to be.

So I think at some point you need to be able to reward improvement over time, and I think you also, when we have more information and we’re able to be more confident about setting levels of acceptable care, that we might want to pay on that as well. I think a good pay for performance system will basically incorporate measures of all three types of good performance so that we can have rewards for the folks who do it right, incentives for the folks who aren’t quite there yet but are improving, and then some more explicit recognition of the fact that you really need to be at a certain level in order to be considered a top-notch provider.

The U.S. health care system comes up smelling like a putrid rose in a survey that compares how citizens in 10 countries feel about their nation’s health care situation.

The report on the survey–actually, several surveys combined–published by Harris Interactive can be found here.

While the  finding that Americans don’t like their health care system surprises no one, it is interesting to see that the other health care systems reviewed also have many detractors. The Harris Interactive researchers sum up their findings this way:

• Regardless of what system a country has, it falls short of public expectations. Most health care systems appear to be continuously in or on the brink of crisis.
•  Governments in all 10 countries that were studied are either changing or debating how to change their system.

The American Medical Association has issued an apology for its long tradition of racial inequality toward black physicians and for accepting segregation within the medical profession.

Institutional racism such as that fostered by the powerful AMA is one of the insidious forces that has contributed to America’s shameful history of white privilege.

I suspect that the rise of Barack Obama as a presidential candidate is forcing many institutions to realize that, within a few months, a black man may become the most powerful person in the world. Funny how power shifts like that.

A new bus is pulling out of the station, and it’s time for every American institution to get on board.

It is always surprising to me that physicians perceive themselves to be victims of America’s health care crisis when, in fact, they are the only ones that can save the system. I don’t blame physicians for the problems–there is too much blame to go around to pin it on just one group–but physicians alone have the power to sabotage any proposed reforms.

That’s real power, and that means physicians must be on board with any changes designed to return from the brink. And the only way they will be truly on board is if they help design the changes. Physicians, America needs you to apply the intelligence that got you through medical school to the nation’s health care quality and cost crisis. No, most of you did not sign up for this when you decided to become a physician, but you are the key to solving this mess. So please, proceed with haste.

Robert Laszewski, president of Health Policy and Strategy Associates and one of health care’s truth tellers, says this nicely in his recent post.

For one thing, the pharmaceutical companies have to pay for all that lobbying effort.  Getting Congress to do your bidding does not come cheap.

The Wall Street Journal reports on a Center for Public Integrity report that the pharmaceutical industry spent $168 million lobbying Congress in 2007, up 32 percent from the previous year.

The Medicare Payment Advisory Commission, which guides the nation’s largest health care payer, is suggesting major changes to the way health care is delivered in America. 

The high cost of health care threatens to overwhelm the United States’ ability to pay for it–and yet the growth of the health care industry is the one bright spot on the country’s economic radar screen.

Huh?

When Peter Orszag, director of the Congressional Budget Office, testifies before the Senate Finance Committee at its health reform summit next week, we can be sure he will pound the drum he has been beating for more than a year: “The rising cost of health care represents the nation’s single most important long-term fiscal challenge.”

And yet the health care industry may be the economy’s savior, reports today’s Washington Post:

By 2016, the Bureau of Labor Statistics predicts health-care employment to double the projected growth of all other industries combined.

“It’s one of those industries that doesn’t seem to be affected by economic downturn,” said Terry Schau, an economist at the bureau. “People get sick, and they’re going to need health care. The state of the economy may affect their ability to pay but not the demand.”

It may not take much more press like this before hospitals may start giving up their tax-exempt status voluntarily.

As reported on the WSJ’s Health Blog, Sen. Charles Grassley is turning the heat on hospitals that get tax-exempt status, questioning whether their public service warrants the special treatment.  The pressure is only going to build on this issue, as hospitals become ever-more business-savvy to compete in a time of a declining reimbursement rates.

Physicians who do not like pay-for-performance programs may rue the day they started complaining about them.

P4P programs, which generally keep patients out of the mix, are easy to accept in comparison to public rating systems that reward patients, via lower copayments, for learning which physicians offer the highest quality care at the lowest cost and taking their symptoms to those doctors.

Physicians are understandly nervous about ratings, which can be misleading or downright wrong. But payers–frustrated that the P4P movement is going nowhere fast–are looking for new ways to reward physicians who will get in line with payers’ cost-effectiveness goals, and physician ratings is one of them.

In Massachusetts, the state medical society sued Group Insurance Commission, which buys insurance for more than 300,000 current and retired state employers, claiming that its physician rating system “fraudulently misleads patients and unfairly affects the reputation of physicians.”

No quaking in Massachusetts. Other payers are undaunted. As reported in the Boston Globe, two of that state’s biggest health plans are moving ahead with physician rating systems instead of waiting for the lawsuit to play out.

The New York state Medicaid program is the latest to announce it’s going to stop paying for some of the so-called health care that hospitals provide that, in fact, hurts more than it helps. Wrong-site surgery, anyone? Foreign object left in during surgery?

FierceHealthcare reports on the latest payer to make the seemingly common-sense move to stop paying for preventable medical errors:

New York’s Medicaid program has decided to stop reimbursing for avoidable hospital complications and medical errors it considers to be “never events.” Starting in October, it won’t pay for care related to 14 conditions, including wrong-site surgery; foreign objects left in the body; medication errors; blood incompatibility; contaminated drugs and patient disability from electric shock. Hospitals that want to receive Medicaid payments will have to prove that such conditions were present on admission to get paid for treating them. Meanwhile, the state expects to keep expanding this list.

This trend, which now includes Centers for Medicare &  Medicaid Services, CIGNA, WellPoint, and lots of others, makes so much sense…and yet why does this feel like a raft of unintended consequences getting ready to be revealed?

It is regrettable that hospital administrators do not recognize, let alone deal with, the unacceptability of preventable medical errors until payers start refusing to send the checks. There’s no doubt that the financial consequences of poor practices that result in infections and other serious medical harm will get hospitals to change their ways. But at what cost? The bureaucracy that is being built up to make the “no pay” trend work will be substantial, adding to the high cost of care. And the high cost of care translates into reduced access for some patients.

Term limits for legislators seemed like a good idea until they were passed–and now they look like big problems. I wonder if we’ll say the same thing about the ‘never event’ trend some day.