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Friday, May 18th 2007

Improving Health Care

Even putting aside Medicare pay-for-performance (which is coming for reasons other than promoting quality), improving the quality of health care has to be second only to covering the uninsured in terms of the focus being put on health care issues.

It seems the biggest piece of pie on the IOM’s agenda (also here and here), it of course is a major focus of the AHRQ (listen to their podcasts), and it even has a current Ad Council campaign encouraging patients to get more involved in their health care to help prevent medical errors:

I Just Hope To Be Able To Break Out Into Song
At Least Once During My Third Year

Despite the fact the public vastly underestimates best guesses at the number of lives lost to medical errors, proving a need to inform on the issue, we should be careful in how the “crisis” of medical errors and attempts to improve quality are presented.

“Dumbing down” the story, such a big part of the media’s job on all complex issues, is a necessity. But in doing so, even attempts to present innovation and steps in the right direction have the potential to irresponsibly raise the public’s expectations and eventually cost the medical profession part of its most prized possession – respect.

The fact public perception of physicians hasn’t been dragged down by the swelling of concern for the state of the American health care system is a wonderful sign. But it isn’t an unreasonable fear that the numbers could turn.

Take the New York Times article which prompted this post. It is part of a series on health care quality improvement (another sign of the power of this particular issue). Not only is it light on the facts but it often presents a point without giving voice to the counter argument.

The article deals with the development of a “warranty” program by Geisinger Health System of Pennsylvania for elective CABGs.

Taking a cue from the makers of television sets, washing machines and consumer products, Geisinger essentially guarantees its workmanship, charging a flat fee that includes 90 days of follow-up treatment.

Even if a patient suffers complications or has to come back to the hospital, Geisinger promises not to send the insurer another bill.

There’s some novelty in the hospital’s ‘bundled payment’ being self imposed and the implications of that, but efforts throughout the decades to place the financial risk for care on hospitals (per diem, the DRG, capitation) while having primarily cost control motives, also had hopes of improving patient care…without success. The article focuses mostly on this idea of a “warranty,” but, the article probably misses the major driving force for quality improvement in Geisinger’s ProvenCare program. The program adds a pay-for-performance element to the reimbursement of Geisinger’s physicians. The NYT’s article doesn’t even really mention that.

As the article briefly touches on, Geisinger is a vertically integrated HMO. The only reason this experiment is possible is because it acts as insurer and physician employer,

Another Geisinger edge is that it directly employs the bulk of the doctors who practice at its hospitals. That is in contrast to most hospital systems, even the country’s biggest and best, where doctors typically act as independent contractors — making it harder for a hospital to coax them toward a uniform set of procedures, and often leaving it unclear who is responsible for follow-up care.

“The degree of fragmentation of care also limits how generalizable this model is,” said Dr. Hoangmai H. Pham, a senior researcher at the Center for Studying Health System Change, a nonprofit group in Washington.

Don’t forget the number of payers and insurance providers who would need to be on board .

Consider trying to implement a “warranty” at your more traditional private hospital without a many payer(s) on board. Sounds like a train wreck of an idea. No pressure for the surgeons to improve their care because they’re still getting their fee and a whole host of other insurmountable obstacles.

Such is why P4P is being driven by the payers, namely the largest one. Also because they’re the ones such programs will benefit financially…but that’s been covered in depth by the medical blogosphere.

With all that said, the biggest problem though is that when you finish the article you feel like Henry Ford needs to take control of the American health care system.

In almost no other field would consumers tolerate the frequency of error that is common in medicine, Dr. Berwick said, and Geisinger has managed to reduce the rate significantly. “Getting everything right is really, really hard,” he said.

Around the world, other modern industries — whether car manufacturing or computer chip making — have long understood the importance of improving each piece of the production process to tamp down costs and improve overall quality.

Let’s compare apples to apples.


First, the complexity, and more importantly variation, in caring for a patient pre and post CABG compared to building a television makes the two far, far, far from analogous.

Second, it is largely the automation and standardization of manufacturing which has allowed the rise of corporate guarantees and warranties. By its nature medicine will never come close to such automation any time soon.

I trust the American patient smart enough to just inherently know that there’s something different about medical care than any other industry. But with constant inundation of the argument medicine should be taking lessons from manufacturing and with arguments for P4P being targeted to patients themselves, who knows where their opinion will turn.