Sunday, October 16, 2011

Clouded visions of purity and virtue

In an op-ed entitled, "The Thing Itself," New York Times columnist David Brooks decries the fact that, in this polarized political environment, "many issues that were once concrete and practical are distorted because they have become symbolic and spiritual."  "Nearly every practical question becomes a values question," he notes, and "to compromise on any front is to court disaster."  "There are rewards for those who fight over symbols, few who see the thing itself."  And, then, with regard to one specific program that had become a policy disaster, he explained that "its champions ignored basic practical considerations.  They were befogged by their own visions of purity and virtue."

I think this is a good appraisal of the current state of the body politic, and I am struck by how often it applies in the health care arena.  Let's face it, the issues are pretty straightforward -- providing access to health care; shifting our focus from a system based on the high-end "rule of rescue" to one based on a thorough system of primary care, prevention, and early detection; paying special attention to the management of care of the 15% of the population who account for 85% of the costs; reducing the amount of preventable harm in clinical settings; and introducing techniques of process improvement that have been proven to work in so many other sectors.  Those, to use Brooks' terms, are "the thing itself."  But then we surround them with ideology and a lack of analytical rigor in policy-making, and we end up with a stalemate, lack of progress, or, maybe worse, unintended consequences.  Let me give three examples:

The Community Living Assistance Services (CLASS) Act, inserted into the health care reform legislation, was intended to be a voluntary program open to all working Americans. It would have provided a basic lifetime benefit of a least $50 a day in the event of illness or disability, to be used to pay for even non-medical needs, such as making a house wheelchair-accessible or hiring a home caregiver to assist with basic tasks.

As noted in the Washington Post, "The program was to be entirely self-financed with the premiums participants paid. Obama officials said that presented them with a problem: If they designed a benefits package generous enough to meet the law’s requirements, they would have had to set premiums so high that few healthy people would enroll. And without a large share of healthy people in the pool, the CLASS plan would have become even more expensive, forcing the government to raise premiums even higher, to the point of the program’s collapse."

All of this was obvious to many observers when the bill was being considered, and so it is no surprise that the administration had to conclude that the program was infeasible.  But look at this response:

“I’m very disappointed,” said Connie Garner, who helped draft the CLASS Act while on the staff of the late senator Edward M. Kennedy (D-Mass.).  “CLASS is a critical backstop, giving working families a tool to protect themselves from being one illness or injury away from poverty,” said Garner, who directs a group called Advance CLASS Inc. “The president promised to implement this program. We expect him to keep that promise.”

As discussed here many times, the concept of capitated, or global, payments as a replacement for fee-for-service pricing has interesting pro's and con's.  As to the key question of whether it will produce better outcomes at lower costs, though, it does not have much empirical support.

Where this is empirical support, I have found two categories of interest.  The first is those companies, like Commonwealth Care Alliance, who have taken on the care of small populations of dual eligible patients, those on both Medicare and Medicaid.  They have figured out how to manage those patients on a budget much more efficiently compared to those patients who, in essence, navigate their own way through the health care system.  This is good, although the situation with which they are compared is scarcely a paragon of anything.

The second is those systems, like Geisinger, that own both an insurance company and a provider network and are therefore able to optimize costs and transfer prices internal to their financial bottom line, and who are dominant providers in their market area.

But these kinds of example are few and far between and are not representative of the health care system.  Accordingly, there seem to be two main groups who support capitation.   One group does it for business purposes related to a corporate goal of shifting risk.  The other group adopts the rhetoric that all doctors want to do is order expensive tests and procedures to make more money.  Here's one summary from an advocacy group:

Under the global payment structure, docs are paid a set amount of money for each patient they care for, rather than for each procedure or test they provide. So, the providers have incentive to increase efficiency and better coordinate care between nurses, primary care physicians (PCPs) and specialists. 

And more of their "analysis:" 

The current fee-for-service system rewards the quantity of care over quality. You have to go to a doctor’s office or a hospital to be seen and to be tested. Each one of those visits is charged separately. There’s no incentive to do it any other way because the visits and the tests are how the doctor and the hospital make their money.

Global payments support more nurses, community health workers and cost-effective help, like online consultations or home visits. Public health must be integral to this structure as well.

When wishful thinking and rhetoric take over in a policy debate, unintended consequences arise.  This same group, for example, expressed surprised concerns "about narrowing patients’ choices for medical care," something that is inherent in the limited networks you need to make capitated payment regimes work.  Should we be relieved to know that this group "will watch to make sure residents get the care they need?

Re-admitting -- "Never" again
In the absence of a analytical support that might diagnose a particular problem in a rigorous fashion, regulatory agencies will do what regulatory agencies do:  Accept the rhetoric of their political leaders and use the hammer in their hand and see everything as a nail.

I have addressed this problem with regard to so-called never events:

In the face of slow progress, there is little doubt why the regulatory hammer is employed. But it is a crude tool. Its effectiveness as a deterrent is minimal because it does not address the structural issues underlying the problem. It emphasizes a particular outcome rather than a process that will achieve it. It penalizes people when it is too late to make a difference. Finally, it serves mainly to create resentment among those who are targets for improvement. Such is often the nature of regulation, no matter how well intended.

The target de jour is readmissions.  The Boston Globe notes:  "President Obama and members of Congress have cited high numbers of hospital readmissions as a main driver of soaring health care costs, as well as being bad for patients."  The Wall Street Journal explains that at a town-hall meeting the President  compared readmitting a patient to the hospital to bringing a car back to the mechanic -- as inapt a comparison as one could imagine.  He asserts, "And too often we’re not seeing the best practices in some of these hospitals to prevent people from being readmitted. That costs a lot of money."

This leads to the following policy prescriptions:

Starting in 2013, those with the highest rates could be docked Medicare payments. The health and human services department has pledged $500 million to help hospitals partner with community-based organizations that help patients make the transition from a hospital bed to their home.

Wow, this feels like foreign policy.  There, we pound the table and assertively define the enemy to show that we are manly and powerful leaders -- before we are accused of weakness by the other party.  We impose sanctions and supply armaments to the opposing forces, and we find ourselves in a quagmire.  In health care, we grab on to one of many interrelated clinical issues and define it to be a "main driver" and both penalize providers and throw money at the problem.  As in foreign policy decisions, I predict many unintended consequences.


Anonymous said...

I understand your point if readmissions were dealt with on a case by case basis. But they are not. The rules stipulate aggregate risk-adjusted readmission rates over time here. Also, we are not talking about absolute rates but relative rates. If a hospital is doing considerably worse than most hospitals on a consistent basis with respect to readmissions then thats when the penalties come into play. The penalties are not every single readmission. They are also not throwing money at the problem. Any pay for performance measurement should have a balanced measurement approach. Having the right mix of process and outcome measures is essential. While readmission measures may not measure quality accurately (they dont need to) they do an adequate enough job in differentiating good hospitals from bad. BTW, despite the difference of opinion, I am a fan of your blog!

Paul Levy said...

Sorry, there is absolutely no support for this conclusion: "they do an adequate enough job in differentiating good hospitals from bad."

e-Patient Dave said...

Informative and insightful analysis, IMO.

Honestly, I wonder if this desk-banging and redefining of what's going on would all evaporate if we ignored those speakers and directly asked families (citizens) what's important to THEM for their patients.

Government by proxy so often seems to end up serving the interests of the proxies.

Anonymous said...

I think the readmission rate is high because they were sent home to soon, in order to save money no less.

A lot of the elderly population do not have anyone to take care of them, or the caregiver is as sick as the patient.

Do not understand directions or did when they left but don't remember. And there is the "drop off" where the families do not want or can not take care of them any more

Anonymous said...

It is maddening that policy is sold as science, when it should be sold as 'data that really powerful businesses really like'. In the hands of business, even good data is a tool of destruction. Readmission rates will definitely go down. But with no money for health education/literacy, provider training, preventative health, social services, what will go up?

What if healthcare policy were about science? Well, we just keep producing, as if volume and specificity make up for the tiny megaphone. We know that healthy environments make healthy people - across the lifespan - with a very small percentage of those with disease not attributable to environmental determinants (epigenetic or higher order). We know that poison in the air and water impacts what we breathe, drink, and eat; that green space increases mental health; and, that neoplasms most often originate on damaged/insulted cells. We know that people can cause stress and harm or support and healing to each other.

But science is not what drives healthcare. Great and awful compromises with power and money drive social investments and policies about healthcare. No matter how many times we deceive ourselves - as if a park, a school, a healthy workplace are more expensive than a drug trial or proton-beam magic wand - we will respond far too short to make a difference. We cannot answer the questions you ask, Paul, without knowing what we value.