The New York Times has a great article on hospital pricing and cost control. I don’t have time to get into it now. However there is an interesting vignette at the bottom of the article that I need to highlight:
Changes also involved bypass surgery in a project led by Dr. David A. Bull, chief of cardiothoracic surgery at the University of Utah. He and his colleagues asked what variables made a difference in costs and outcomes, hoping to improve both.
That led them to nine measures they called “perfect care,” the primary determinants of how long a patient stays in the hospital after surgery, which is a major contributor to costs and a harbinger of poorer outcomes.
The variables included such practices as keeping blood sugar under control — 75 percent of their bypass patients had diabetes — and giving oxygen to patients who are having trouble breathing when they are taken off the ventilator. The usual quality measures, like giving antibiotics before surgery, did not affect length of stay. [emphasis mine]
The group standardized the care after surgery with those nine items in mind, and nurses were permitted to give medications or oxygen without having to contact a doctor first.
Some were skeptical the program would make a difference, Dr. Bull said. But costs fell by 30 percent because patients spent less time in the hospital and had fewer complications.
Paying for quality is a wonderful goal. But we have a damn hard time determining what quality care looks like. Checklists are probably a part of that process, as well as standards of expected care, but our currently accessible data sources (mainly things which are mandatory fields in for a claim to be paid) may be lacking.
It is what our health system should be doing. But if the current metrics don’t correlate at all to improved care, our quality system if worse than useless. We need to develop better metrics, better markers and better processes that produce system wins (lower costs) and patient wins (fewer complications and feeling better at the end of the process.) If we pay based on useless metrics, we are poking ourselves in the eye with a screwdriver while wondering why we can’t see anything besides red.
Fair Economist
My immediate thought on reading the article was “what were the other seven worthwhile actions” – which aren’t in the NY Times article, anything they link, or on a quick google search. Hmmm.
Punchy
I read the post’s title and thought you were going to give a real metered discussion on units. Instead, by any yardstick, the topic is quite different. Different by lots. An inch-by-inch breakdown of costs. What it takes to kilogram is to deny Graham meds when he’s very sick. If they go the whole mile and supply Milly liters of fluids, will her kidney prognosis improve?
It all comes down to footing the bills for the uninsured, I’m afraid.
Tom Levenson
This is, IMHO, one of the most important popular pieces on health care since Gawande’s New Yorker article on McAllen, TX. The central point of today’s piece is that hospitals don’t have a clue what it costs to provide care; that cost was thought to be unknowable; and now it appears that it is not.
Doing that basic task — figuring out how much scratch it actually takes to do anything (and everything) to/for a patient — is the key to so much in delivering health care to everyone in a technically successful, socially achievable setting….I may post on this later, if I have time, and Richard’s point gets its due.
srv
I don’t suppose these American doctors look at what Japanese or Swiss doctors do wrt to qualitative metrics. Isn’t that what we have Wharton grads for? I mean, it’s 2015, not 1955.
But then am not sure Americans, who are 100% diabetic or pre-diabetic can be measured against the rest of the world.
RSA
In the past few years I’ve been talking with physicians about collaboration, research projects that involve computer scientists and medical personnel. Finding out “what variables made a difference” in outcomes is much more challenging than it might sound; I wouldn’t be surprised if a project like the one mentioned took months or even years to reach conclusions.
greennotGreen
Isn’t that one of the things Obamacare was designed to address? You know, “death panels”, because somehow, knowing what works and what doesn’t to extend health and/or quality of life is the same thing as denying care to old folks.
/snark
Roger Moore
@Tom Levenson:
That might be overstating it at least a bit. There are some areas where people have figured out a lot about what works and what doesn’t, but we’re doing a terrible job at getting that information out to the doctors who are supposed to be making use of it. Basically, we tend to treat medicine as an art, where physicians are supposed to make decisions based on their personal experience and preferences, rather than a science, where they are supposed to keep up with the latest thinking and follow rigorously developed guidelines intended to produce good care. Some of the best patient care organizations are actually following the science model, and that’s part of the reason they are the best.
CrustyDem
@Tom Levenson:
It’s actually worse, they have no idea how to provide quality care. Everybody does their job with blinders on and assumes that’s the best way to manage things..
The downside to this is I can imagine every hospital official deciding they’ll be investigating quality, resulting in a pile of spreadsheets suggesting that patient care could be improved by providing a balance of bodily humours.
Or, put another way: “THE MBA’S SAY WE NEED MORE LEACHES!!!”
Tom Levenson
@Roger Moore: @CrustyDem: ;-)
cthulhu
This does not surprise me at all. There’s a very well-regarded ID specialist at UCLA who has been trying, against much resistance, to stop this practice (and for after surgery) because it simply doesn’t work. The only thing that makes any difference for risk of infection is to apply antibiotics directly to the surgical area. Giving systemic antibiotics contribute to AB resistance without improving outcomes. Hopefully the field will catch up eventually as there is more pressure for outcomes research under Obamacare.
japa21
A lot of this is being done and driven by the insurance companies. Depending on the insurance carrier the name is different but the gist is, the providers are accountable for the care they give. This is driven by payment. If care improves and overall costs go down, the providers are rewarded. If not they are penalized. Medicare is doing the same thing.
It behooves the systems to find out the truly best practices which improve outcomes because it isn’t just lower costs that are involved. Patient impact is also considered.
Schlemazel
The solution is obvious! If shorter stay = better outcome then making heart surgery an out patient procedure is a real winner . . . says the insurance CEO
piratedan
well I can state that part of the issue is the tremendous amount of paperwork/documentation that accompanies each and every action that is taken by anyone for the simple fact of tracking costs… not as a measure of benefit gained by the patient, but to simply document and code for the case of billing and authorization what was done. Also the fact that we have a whole boatload of data to be analyzed but no one has the time to interpret and understand what it all means. The clinical laboratory craps out oodles of information each and every day performing the requested analysis of various and sundry body samples, every thing from the most commonplace, blood and urine to be able to isolate the types of bugs that may or may not be swimming in various body fluids, be they in your chest cavity, you spinal column or your knee. They can plow through your fecal matter like a forensic detective. The scary part is, while they can provide an analysis or measurement of certain values that are contained within, your local everyday physician only has a cursory knowledge of what all of this data means. You have to remember that your everyday clinician is NOT Dr. House, as such, there’s got to be a better way to integrate the data that can be obtained and filed with an idea of establishing both what is normal for the patient and what treatment might be most effective to help them get to a healthier place.
Mnemosyne (iPhone)
@piratedan:
Would it also help to have a single set of codes that everyone has to use rather than each insurance company having their own unique codes? I can’t remember if that was something that Obamacare was supposed to address.
piratedan
@Mnemosyne (iPhone): its true to an extent, if you want to classify the ICD series of codes (ICD 10 is out now) but the thing is, they are mainly used to identify illnesses. There are other procedures and protocols that get worked into all of this that aren’t standardized because every system has it’s own quirks and methodology to it when it comes to providing analysis of the clinical data (if they even do so because then you’re into a very vague area of medical instrumentation and that is regulated by the FDA).. say you have someone that comes in with a group of unspecific symptoms, say headaches or fatigue… that can end up being damn near anything and docs have to run down a daisy chain of possibilities before they may arrive at a more specific diagnosis. The end result being having to justify everything that they did before they got there and then what the insurance company may cover.
lahke
@piratedan:
True that the labs and the providers data systems have the results, but they don’t get back to the insurance company, so are never linked to the utilization and cost data. I work for an insurance company (non-profit! good guys! best quality ratings in the country!), and it’s uphill work to get that lab data back –we get the claims, mind you, so that they can get paid, but we don’t get the results without extra effort, and then not for everybody.
@Mnemosyne(iPhone): all the diagnosis and procedure codes are standardized now, and in Massachusetts, all the other elements on claims are standardized also (thank you, State Sen. Karen Spilka!).
Believe me, linking utilization and costs to health outcomes is the holy grail, and we all want it because making a patient take useless drugs and do unneeded procedures is not just expensive, but it adds risk. Next of course, is to get the doctors to actually do the right things–though maybe they’re waiting for final, final proof.
J R in WV
I have had two total shoulder joint replacement procedures, in February and in June. One night in the hospital in what they call their Joint Connection ward. No patients except for orthopedic surgeries. One night, released to go home the next afternoon.
They require patients to attend a class prior to their surgery appointment, to visit the Joint Connection ward, and they teach (mostly knee/hip patients) about the rehab expectations. I was surprised to see that all the other patients were very overweight and in poor physical condition.
I’m 64, 6 feet tall and 240 lbs. But I’m also husky and strong as my hobbies are building projects (houses, barns, workshops, etc) and rock collecting, using shovels and picks to dig, and sledge hammers and chisels to extract minerals or fossils from bedrock. My shoulder operations took twice as long as expected as they had trouble retracting muscles that were larger and stronger than usual.
Before the surgery we were instructed to shower both in the evening and in the morning with a special anti-bacterial soap, I presume to combat MERSA infections. IIRC the process was developed out in CA and has spread slowly to progressive surgeons. I’ve had little trouble and am in rehab for my left shoulder, with a couple of months to go to recover mobility and begin working on strength.
They seem to have a grip, and with my state insurance costs were very reasonable, especially since my surgeon’s scheduler changed my second surgery appointment to just before the annual benefit year restarts, so my deductables were all met by the first operation. My second surgery was nearly nothing out-of-pocket, which was a real relief!
Then last month I had an annual physical at my family practice Dr, who was running ahead of his normally backed up schedule. He told me that everyone was changing to all new codes for everything, and it was going to save him a huge amount of time. He had a nurse staying right with him as he did final write-ups, she seemed to be a savant for remembering the proper new codes. They would either agree and go on, or he would leaf through the book for the new code.
He was really happy that the new codes were going to save him a lot of time spent on bookkeeping, which he would rather use for patient care. Amazing, how things done by professionals seem to work out well, as opposed to things dreamed up by politicians without guidance from those who know what they’re doing!
Thoughtful Today
[sigh]
This is my specific problem with Richard’s corporate insurance approach: Corporate insurers dictate health care without any medical training.
Richard is selling corporate insurance, his job relies on it whether it’s Goodwill Inc. type ‘nonprofit’ or not.
Nor is it likely that in any foreseeable decade will the corporate insurance approach favored by Richard and his neoliberal supporters ever provide Universal Health Care.
But as others have noted, a person’s personal paycheck often define the possibilities they see in the world. That in this case it leaves millions, literally millions, without healthcare is an abomination.
Richard’s paycheck makes him deeply antagonistic, even insulting, to the successful paths dozens of other countries have used to achieve Universal Healthcare.
GHayduke (formerly lojasmo)
@Thoughtful Today:
Though I agree that single payer is best, your use of neoliberal, your baseless accusation against Richard, and your misunderstanding regarding the state of the situation in the US prove that you are a somewhat foolish troll.
Richard Mayhew
@Thoughtful Today: wow, the article in question raises a critical point of best practices for patient outcomes (minimize complications, minimize hospital time) and how what we pay as best practices don’t actually correlate with good outcomes. I agree that this is a big problem ( it is also a problem that OHIP has) and you make it a chance to insult me.
The conversation is going way over your head… So please feel the bern at the kiddie table
Thoughtful Today
When insurance agents says, “we have a damn hard time determining what quality care looks like”, remind yourself (again) that insurance agents are not Doctors.
Crusty Dem
@Thoughtful Today:
And if you understood the article, the point is the DOCTORS don’t even understand the details of how to deliver proper care. How that’s Richard’s fault is more an experiment in identifying your own delusions..
Thoughtful Today
An easy place to start for comparisons is OECD or WHO data, or easier still, simple Factbook rankings.
For advanced research try Pubmed citations.
This oldie but goodie is for you, Richard: “We’re Number 37!”
Richard Mayhew
@Thoughtful Today: go fuck yourself
Thoughtful Today
heh, classic,
Richard, in numerous threads now, repeatedly dismissed anyone that disagrees with his corporate insurance bureaucratese as belonging at the “kiddie table” and often follows that with the equivalent of his above, “go fuck yourself”.
… and he complains about being insulted…
Keeping selling that insurance, Dick.
Thoughtful Today
Richard, sincerely, hopefully you’re helping those trying to navigate the Rube Goldberg insurance system we’re unnecessarily burdened with.
I’ll keep pointing out that talk about costs before health, looking first at “system wins (lower costs)” before the “patient wins”, is backwards.
Richard Mayhew
@Thoughtful Today: You don’t do your homework (as numerous people have pointed out single payer is not the only pathway to covering most if not all people in a country —see Germany, see Japan, see Netherlands, see Switzerland etc) and you refuse to learn, so again, you add nothing to the conversation
Aardvark Cheeselog
@Richard Mayhew: Please do not feed the troll.
Richard Mayhew
@Aardvark Cheeselog: You’re right, that was a pre-coffee response that was not needed.