The Clock Is Ticking

Who knows what the Supreme Court will say about the ACA. Strange, isn't it, how something so far from politics as health care will break along predictable political lines in the court, with one swing vote, as usual, being decisive. Whatever they decide, our health care system will remain astoundingly dysfunctional.

While politicians politicate, Medicare is testing new approaches to paying hospitals and docs; namely by paying lump sums for the management of a particular diagnosis/operation. Some say it's working.

If a hospital delivered care for less than the bundled rate, while hitting certain quality metrics, it would keep the difference as profit. But if costs were high and quality was too low, Baptist would lose money. For the first time in their careers, the doctors’ paychecks depended on the quality of the care they provided.

Four surgeons quit in protest.

“I’d describe the reception as lukewarm at best,” Zucker says. “There was a lot of: ‘How could you do this?’ and ‘I’m not going to participate.’ ”

The program launched in June 2009 with a checklist of quality metrics. To earn a bonus, surgeons would, among other things, need to ensure that antibiotics were administered an hour before surgery and halted 24 hours after, reducing the chances of costly complications.

Only three doctors hit the metrics that first month, but their bonuses caught the attention of others. “There was a lot of, ‘Why are those doctors getting more, and I’m not?” Zucker says. Eight doctors got bonus payments in July; two dozen got them in August. Compliance with certain quality metrics steadily climbed from 89 percent to 98 percent in three months.

Two-and-a-half years later, Baptists’ surgeons have earned more than $950,000 in bonuses. Medicare, meanwhile, has netted savings: Its bundled rate is about 5 percent lower than all the fees it used to pay out for the same services.

When I was in training, we were told that pre-op antibiotics had to be given at least an hour before the operation started; the opposite, in other words, of now. The idea was that it took that long to establish effective tissue levels, as opposed to blood levels, of the drug. Whatever. I'm certainly in favor of testing old theories and establishing new procedures based on new data. But that's not my point. The point is that tracking the timing of antibiotic delivery is as easy as it is arbitrary. Fifty-nine minutes: good. Sixty one: fail.

I've seen borderline panic when, for any of several trivial reasons, it looks like knife might not be laid to flesh within the one-hour window. A minute too long, you get dinged. It's pretty stupid, ask me. Does a minute or two make any measurable difference in surgical outcomes? Take a wild guess.

But it's a parameter. And it's simple, binary, yea or nay. Ding or dong. Because it's easy, there it is. It's a hell of a lot harder to compare, say, two patients who had the same part of their colon removed for the same reason: one whose operation takes an hour and who goes home in a couple of days; the other who was in the OR for four hours and went home in over a week. Is it because the second surgeon screwed up? Did s/he take too long because s/he wasn't well-enough trained; did the patient languish because of preventable problems, poor (or, in the case of laparoscopic colon resection, unnecessarily expensive) technique, out-of-date post op management?

Because I knew how to carry out an operation efficiently, because of ways I managed their post op care, my patients were in the OR an hour or two less than other's, went home a couple of days sooner than average, happy. Total costs when I did a colon resection were thousands of dollars less than nearly every other surgeon in the state (it was actually tracked at one time, until other surgeons hollered.) Had there been in place, back then, a system of rewards for such superior care (yeah, go ahead, say it...), not only would I have made out like a ... surgeon who provided superior care, but there'd have been pressure on my colleagues to figure out what I was doing (they could just ask!), and do it, too. A win-win for patients, docs, and hospitals.

But there are factors in every case that are nearly impossible to quantify and compare: the patient's body habitus, the effects of meds they might be on, the amount of inflammation in the area operated, tumor size (if that's what it was about), adherence, circulatory issues, and a lot more. Anesthesiologists categorize patients into five risk groups (six, if you include brain-dead organ donors): the higher, the more they charge. So far there's not a reliable system for doing the same for operative difficulty and postop risk. (There's a code or two for higher degree of difficulty, which theoretically increases the surgeon's reimbursement; but not a hell of a lot. And, far as I know, it doesn't affect "package pricing." I could be wrong about that.)

So what happens when package pricing is in effect? What happens when things are a little tough in the operation? Would some surgeons look for shortcuts so as not to have extra surgical charges on their record? Would patients be pressured to go home a little too soon?

Neither, in my experience, is too likely; and I'm certainly not the first to raise the question. But despite what you might have heard, surgeons are human. And when there's money on the line, when records are kept about individual docs in the form of "economic credentialing," things change. Might surgeons and hospitals tend not to accept patients whose care looked like it'd be too costly? And what would that do to referral hospitals? Would they and their surgeons lose even more money than they are now? How long would it take -- or would it be possible at all -- to get their package price upped to reflect the level of care they're providing?

I greatly admire the Democrats' attempts to make economic sense of it, however flawed; and I absolutely reject the typical R dodge that letting "market forces" take care of it will, in fact, take care of it. It's what's been in play for decades: how's it going?

This is why I think "effectiveness research" is so important, and why it's literally obscene that congressional Rs just voted to eliminate that part of the ACA; the vote is the culmination of stupid, demagogic politicization of something too important to be left to teabaggRs and their imaginary "death panels." Bullshit, codified.

Inefficiencies abound in American health care: systemic ones, economic ones (in the form of allowing health insurers to pocket as profit so much of the money intended for care), and ones related to doctors using various treatment options that have or can or would be shown to be less efficient and less effective than others. Assuming such research were allowed, and assuming the results could be trusted, it'd bring a level of rationality to care that currently exists only sporadically. (My former clinic has received national recognition for being a place where it exists, matter of fact.)

And it would give "cover" to people like me who tried, not always successfully, to convince a patient or family that something they were demanding didn't make sense.