Medicine Driven by Data
This article (read it here) by Lisa Rosetta may be the single most important piece of reporting on our health system in Utah this year. I advise Utahns to read it twice and think about its implications. Here are some excerpts:
In the mid-1990s, only about 40 percent of heart surgery patients nationally were going home with the right medications -- beta blockers, anticoagulants and other potentially lifesaving drugs. Intermountain Healthcare's numbers were better, but not by much. So, in 1997, a research team at the Salt Lake City-based nonprofit health system developed a low-tech solution: a mandatory two-page checklist to help doctors ensure discharged patients get exactly what they need. It was a simple innovation, yet one that yielded impressive results. Within a year, more than 90 percent of patients were getting appropriate medications. Readmission rates at its hospitals went down. Survival rates went up.
Using Intermountain as a benchmark, the 2008 Dartmouth report says, the nation could reduce health care spending on acute and chronic illnesses by as much as 40 percent. The report also said Intermountain has driven down unnecessary "supply sensitive care" -- or care that tends to be provided because hospital beds, doctors and specialized equipment are abundant, rather than because a patient clearly needs it. If all providers were to achieve Intermountain's level of efficiency in limiting such care, they would see an estimated 43 percent reduction in hospital spending, Dartmouth said.
Within six months of the initiative, however, the rate of early-elective deliveries at Intermountain hospitals dropped to 10 percent from 28 percent; eight years later, that number is less than 3 percent. But something else happened, too: Intermountain lost money. By performing fewer early-term elective deliveries, the health system saw shorter lengths of stay. NICU admissions dropped. Patients received fewer lab tests, antibiotics and Caesarean-section surgeries. "The bottom line to our cost was significant," Wilson said. An analysis of the impact on the health system revealed it lost $3.3 million in net revenue between 2001 and 2005. And that was a conservative estimate, based only on length of stay in labor and delivery, Wilson said.
It wasn't the first time this had happened. Identifying and implementing best practices in a number of areas -- deep-wound infections, adverse drug events and community-acquired pneumonia, to name a few -- meant the health care system was hemorrhaging millions. It created windfall savings for insurers, James said, "and we were struggling financially." Being a nonprofit helps, he said. So does having a board of directors and an administration that is "mission driven." But it also begs the question whether Intermountain's success can be replicated by other for-profit and nonprofit institutions. Payment reform, Poulsen said, will have to happen first, so health systems aren't punished for providing more effective clinical care. "The incentives today are wrong," he said. "You almost have to make a conscious decision that you will overlook what's in your financial best interest in order to do what's effective, efficient and appropriate ... [and] you know you're asking a lot of human nature to do that." When that happens, the country won't just get more Intermountains, Mayos and Geisingers, James said. "We'll get a level of health care delivery this country just hasn't seen before in terms of the quality of care we offer to patients," he said.
And, he added: "It will be at a reasonable price."
People throughout the United States cling fearfully to the current health care system because of a false fear: They fear that health system change will lessen the quality of the system. We are accustomed to thinking in market terms about health care. If you want better quality, you have to pay more. We pay more for health care in the US, therefore we must have better quality.
WRONG. We pay more in the US for health care because we have poor quality care. What should be feared is the current system, which pays doctors to harm patients. (Dr. Brent James made that statement before Congress this year.)
Notice in this article that a health care system (IHC) which strives to improve care is actually financially punished for better health care delivery, which is less expensive. What market punishes the seller of higher quality services at a lower price? The answer: no market does that. We have perverse incentives in health care in the US. We pay hospitals and doctors more if patients become sicker. Markets don't have perverse incentives. Health care is not a commodity in a market. The sooner we recognize that market principles don't apply to health care, the sooner we will achieve health system reform that is sustainable.
A key component of health system reform that is sustainable is quality improvement. Better quality care always costs less. Health system reform must begin by lowering costs, because we can not afford to pay for the care of the uninsured given our current per capita health costs.
Unfortunately, the private health insurance system is preventing the very quality improvement that we need, both to save patients' lives and reduce our costs. Private health insurance pays doctors to harm patients. Health systems that improve are punished by private health insurance payers.
Thanks to Ms. Rosetta for an excellent article.
Dr. Joe Jarvis