Cutting health care costs through better care delivery

[boedicca]

What's really amusing is that Intermountain Healthcare is focused on these efficiencies all on their own without being ordered to and micromanaged by the HHS. Any properly run health care organization is always seeking productivity improvements (which makes the cost saving assumptions in ObamaCare even more bogus).

To reiterate the point I just made: the unifying theme behind these innovators is that they're integrated care systems, meaning they have a health insurance plan built into their provider network (i.e. they're both the payer and the provider, much like the VHA). There are multiple reasons that setup works well for them (e.g. less fragmentation = better care coordination), but most notably the incentives line up much better for integrated health systems.

In other words, Health Care is experiencing Vertical and Horizontal Consolidation just like any other industry.

Thank you for sharing.

 

[Oddball]

Boring bullshit text wall unread.

Then you have no occasion to post, and any post is meaningless.

Who says you have any say in what's valuable to whom and what isn't?

After all, isn't that the central idea of leaving decisions about medical care in the hands of those receiving it, rather than in those of some unaccountable butt-insky bureaucrat?

 

[boedicca]

Health Care companies operated with a "profit motive".

Yes, the Mayo Clinic has always operated with the idea of making a profit. This has resulted in them being recognized as the best place in the world to go if you are sick.

Do you have a problem with them being the best in the world at what they do?Do you think we should force them to just be mediocre simply because making money is evil? Do you understand that they often treat people without any cost to the patient and still make that evil profit? That profit makes it possible for them to give people care without charging them.

Actually, he does.

Because if some health care is better than others, it's discriminatory that some people get better health care than others. The only people who deserve the Superior Care at the Mayo Clinic are the Very Rich and Famous People who deserve to be our overlords.

They can afford to pay for the Superior Care...which we should be denied even if we wish to pay for it ourselves.

 

[Quantum Windbag]

The unifying them is profit. not the system they use.

Read more carefully: that's the point. Their integrated structure (i.e. simultaneous status as payer and provider) allows them to profit from value improvements, something that's significantly less true of the rest of the delivery system in this country. Hence the emphasis on payment reforms that allow shared savings (shared with providers, not just payers) and accountable care.

I'd love to see providers profit from using high value (i.e. better health outcomes for less money) delivery system innovations. That means the financial incentives have to align, as they (roughly) do in the innovators I've been highlighting in this thread (and even within them there's still room for improving the incentives). Outside of integrated delivery systems, at present those incentives don't align. Hence the problem.

The government cannot provide incentives for private profit by deciding what systems work and what systems do not work. They will always be wrong because they get locked in something that works in one place and believe it will work everywhere. It will not.

As for them not working in non integrated systems, they seem to work quite well in multiple industries that are not integrated. I can even point to many small hospitals that take many different insurance plans that have no problem making money. Yet you, in your infinite stupidity, think that all health care providers should be integrated simply because you found a few examples of some integrated care providers that make money. I can easily find integrated care providers that fail at both controlling costs and making a profit, the VA comes to mind without any thought at all. This despite the fact that military records have been portable for years, and any VA doctor has access to everything ever done to anyone he sees.

Can you tell me what the difference is?

 

[Quantum Windbag]

Boring bullshit text wall unread.

The problem with medical costs it too much third-party interference between the customer and the provider, not "reformed" methods of it.

Not at all. The problem lay with the American health-care system. It is a joke. I, as a Canadian, continue to laugh at it.

Didn't somebody rule that your health care systems actually violates human rights? I think that is a lot funnier than anything happening with our system.

 

[Quantum Windbag]

Not at all. The problem lay with the American health-care system. It is a joke. I, as a Canadian, continue to laugh at it.

Didn't somebody rule that your health care systems actually violates human rights? I think that is a lot funnier than anything happening with our system.

Nowhere did anyone rule our health-care system violated human rights. Unlike in the USA, it is every Canadian's RIGHT to health care. It is actually enshrined in our own Constitution.

I find your remark amusing when one considers that yours is a country that PROFITS from human misery, pain and suffering. 'Ooooh, he needs surgery! Let's bust for a few hundred grand! We can be rich!! Yeah!!'

I see what I am dealing with here, a person who denies reality. I was actually referencing Chaoulli v Quebec which found actually found that the long wait times caused by the lack of private insurance options violate human rights. That means that your courts ruled that health care for profit is actually a human right.

Thanks for playing.

 

[Greenbeard]

I can even point to many small hospitals that take many different insurance plans that have no problem making money.

And?

Yet you, in your infinite stupidity, think that all health care providers should be integrated simply because you found a few examples of some integrated care providers that make money.

Not only have you completely missed the point of this thread, you've missed what my preferences are (and no, they don't involve building a health plan into every provider network). How out of character for you!

 

[Political Junky]

Didn't somebody rule that your health care systems actually violates human rights? I think that is a lot funnier than anything happening with our system.

Nowhere did anyone rule our health-care system violated human rights. Unlike in the USA, it is every Canadian's RIGHT to health care. It is actually enshrined in our own Constitution.

I find your remark amusing when one considers that yours is a country that PROFITS from human misery, pain and suffering. 'Ooooh, he needs surgery! Let's bust for a few hundred grand! We can be rich!! Yeah!!'

I see what I am dealing with here, a person who denies reality. I was actually referencing Chaoulli v Quebec which found actually found that the long wait times caused by the lack of private insurance options violate human rights. That means that your courts ruled that health care for profit is actually a human right.

Thanks for playing.

Most civilized countries find that making a profit on health care is illegal...go fiigure.

 

[Quantum Windbag]

I can even point to many small hospitals that take many different insurance plans that have no problem making money.

And?

Yet you, in your infinite stupidity, think that all health care providers should be integrated simply because you found a few examples of some integrated care providers that make money.

Not only have you completely missed the point of this thread, you've missed what my preferences are (and no, they don't involve building a health plan into every provider network). How out of character for you!

I missed the point of the thread?

I summed it up in my first post. Companies that are focused on making money provide better service at lower costs than the government.

For some reason you think the government has to step in and help companies to make a profit by paying companies to make a profit. How did I miss your preferences again?

 

[Quantum Windbag]

Nowhere did anyone rule our health-care system violated human rights. Unlike in the USA, it is every Canadian's RIGHT to health care. It is actually enshrined in our own Constitution.

I find your remark amusing when one considers that yours is a country that PROFITS from human misery, pain and suffering. 'Ooooh, he needs surgery! Let's bust for a few hundred grand! We can be rich!! Yeah!!'

I see what I am dealing with here, a person who denies reality. I was actually referencing Chaoulli v Quebec which found actually found that the long wait times caused by the lack of private insurance options violate human rights. That means that your courts ruled that health care for profit is actually a human right.

Thanks for playing.

Most civilized countries find that making a profit on health care is illegal...go fiigure.

Except, for some reason, Canada, which just ruled that it actually gives people better health care, which is actually a human right in Canada.

Go figure.

 

[Greenbeard]

I summed it up in my first post. Companies that are focused on making money provide better service at lower costs than the government.

The government doesn't deliver these services, nor is there any proposal out there under which it would. The point is moot.

For some reason you think the government has to step in and help companies to make a profit by paying companies to make a profit. How did I miss your preferences again?

Let me help you out. This thread is about lowering costs (for the consumer) and improving care quality/health outcomes: the value proposition. That's why the title of the thread is what it is. Under current payment structures, increasing value will generally lead to lower profits for a provider, meaning there are structural barriers to enhancing value. No one is arguing that providers can't or don't make profits right now; that's something you've made up in your head (just as you've somehow concluded I want every provider to be in an integrated health system). The fact that the straw man you've created has nothing to do with value--the subject of the thread--is unsurprising.

This isn't a controversial point; it's health economics 101. That's why Pawlenty is proposing payment reform within Medicare and Paul Ryan introduced a bill creating accountable care organizations in Medicare as recently as the last session of Congress. It's why the Intermountain folks noted that even for them, value improvements have been accompanied by financial penalties. It's why BCBS in Massachusetts is experimenting with the Alternative Quality Contract. It's why major commercial insurers got onboard with the federal EHR incentives, offering their own enhanced payments on top of the Medicare/Medicaid incentives to providers demonstrating meaningful use.

 

[syrenn]

Health Care companies operated with a "profit motive".

As opposed to what...a for LOSS don't worry we can tax more motive?

 

[Quantum Windbag]

The government doesn't deliver these services, nor is there any proposal out there under which it would. The point is moot.

I know I am supposed to ignore the people who say that Obamacare is just the first step on the road to having the government actually deliver these services, but I have a hard time ignoring things like that. Especially when these are the same people that are planning the implementation of Obamacare.

Let me help you out. This thread is about lowering costs (for the consumer) and improving care quality/health outcomes: the value proposition. That's why the title of the thread is what it is. Under current payment structures, increasing value will generally lead to lower profits for a provider, meaning there are structural barriers to enhancing value. No one is arguing that providers can't or don't make profits right now; that's something you've made up in your head (just as you've somehow concluded I want every provider to be in an integrated health system). The fact that the straw man you've created has nothing to do with value--the subject of the thread--is unsurprising.

This isn't a controversial point; it's health economics 101. That's why Pawlenty is proposing payment reform within Medicare and Paul Ryan introduced a bill creating accountable care organizations in Medicare as recently as the last session of Congress. It's why the Intermountain folks noted that even for them, value improvements have been accompanied by financial penalties. It's why BCBS in Massachusetts is experimenting with the Alternative Quality Contract. It's why major commercial insurers got onboard with the federal EHR incentives, offering their own enhanced payments on top of the Medicare/Medicaid incentives to providers demonstrating meaningful use.

Major insurers got on board with the reform because it let them lobby the government to cover their expenses, and their risks. Why anyone would think that is a good idea is completely beyond the minds of intelligent people everywhere, but I gave up on people like you actually thinking about things long ago.

"Lowering costs" is what most of your threads are about. Like I said, you seem to think the government has to step and make this possible.

I find it interesting that you make two statements in your post that end up confirming my position and don't even see the disconnect. First you say this.

No one is arguing that providers can't or don't make profits right now; that's something you've made up in your head...

Which is actually stupid because I can point to posts right in this thread where people actually say just that. Then you mention something else in the next paragraph.

It's why the Intermountain folks noted that even for them, value improvements have been accompanied by financial penalties.

Tell me something, why does making a profit cost a company money?

I just came across a report from the Medicare Payment Advisory Commission actually outlines the problem.

http://www.medpac.gov/documents/June03_Entire_Report.pdf

The regulations that are written by bureaucrats in Washington are nuetral or negative toward quality, and actually tend to pay more when providers deliver poor quality than they do for high quality. In other words, they are designed to limit profit by paying companies to deliver bad service. These regulations were written with the goal of increasing quality and making costs lower. Yet, as you have just argued, they actually do just the opposite.

Now you want to add more regulations that are, again, designed to make cost lower and improve quality of care. For some reason you want me to believe that the government will get it right this time, despite amble evidence that they never get regulations right.

The only reform that will work is for the government to get the fuck out of the way and let companies work out the bugs without any help from the government. The government should just make sure that the final product is actually safe, not try to tell companies how to make it safe, and certainly not try telling them how to make money at it.

 

[Oddball]

But politicians and bureaucrats can't possibly be greedy...Right?

 

[Oddball]

I'm trying to recall the first time I saw a bureaucrat tossed for their gross negligence and/or shit job performance.

 

[Oddball]

Those are politicians, not bureaucrats...They remain no matter who gets elected....Please read for comprehension.

And you can feel free knock it off with the large text any time, jackwad.

 

[Quantum Windbag]

Alright, you Americans are confusing me. You all seem to (stupidly) have a problem with the government taking over your healthcare programs, preferring to leave them in the hands of providers whose sole motive is PROFIT. You DO realise the ONLY difference between our two programs (American vs. Canadian) is the middleman. Yours is the insurance companies, who care only that they earn a shitload of money in the form of PROFIT, whilst ours is the government, whose sole raison d'etre is to serve the people who put them into power in the first place, and to rigidly abide by our Charter of Rights when it comes to our healthcare system. It is ILLEGAL in this country to earn a profit via healthcare programs, whilst that is the very reason the US healthcare exists.

Both systems (American and Canadian) collect a pool of money which goes towards paying any medical expenses (Peter helps Paul pay for surgery etc.) with only one difference between the two... your surgery can be refused. Ours cannot, for it is illegal to even consider refusing in this country. Both systems are the same, except for the source of the middleman, and the regulatory practices behind them.

I am at a loss to understand how Americans are fine with corporations profiting from human suffering. That is in itself SICK.

In summary, the American healthcare system is a joke. Why does the rest of the civilised world have a system somewhat similar to our own, whilst the USA remains the SOLE provider of healthcare-for-profit on the planet? The USA is known for immense greed, but this is absolutely disgusting.

What is the average wait time for care in Canada comapared to the same thing in the US? Does the fact that those wait times were found to actually deny people health care, and thus violate your charter of human rights, by Canadian courts not prove that you are actually full of shit about what actually occurs in Canada?

 

[Quantum Windbag]

Alright, you Americans are confusing me. You all seem to (stupidly) have a problem with the government taking over your healthcare programs, preferring to leave them in the hands of providers whose sole motive is PROFIT. You DO realise the ONLY difference between our two programs (American vs. Canadian) is the middleman. Yours is the insurance companies, who care only that they earn a shitload of money in the form of PROFIT, whilst ours is the government, whose sole raison d'etre is to serve the people who put them into power in the first place, and to rigidly abide by our Charter of Rights when it comes to our healthcare system. It is ILLEGAL in this country to earn a profit via healthcare programs, whilst that is the very reason the US healthcare exists.

Both systems (American and Canadian) collect a pool of money which goes towards paying any medical expenses (Peter helps Paul pay for surgery etc.) with only one difference between the two... your surgery can be refused. Ours cannot, for it is illegal to even consider refusing in this country. Both systems are the same, except for the source of the middleman, and the regulatory practices behind them.

I am at a loss to understand how Americans are fine with corporations profiting from human suffering. That is in itself SICK.

In summary, the American healthcare system is a joke. Why does the rest of the civilised world have a system somewhat similar to our own, whilst the USA remains the SOLE provider of healthcare-for-profit on the planet? The USA is known for immense greed, but this is absolutely disgusting.

What is the average wait time for care in Canada comapared to the same thing in the US? Does the fact that those wait times were found to actually deny people health care, and thus violate your charter of human rights, by Canadian courts not prove that you are actually full of shit about what actually occurs in Canada?

So, it is a 'right' for the wealthy to jump the queue simply because they have larger bank accounts? You believe this to be fair? I should also like to remind you that our costs are far lower than yours. You DO understand that hospitals in the USA are allowed to refuse treatment, yes? Not so here.

Joe Blow in the USA is rolled on a gurney into a US hospital. Nurse asks him for his insurance provider. He tells the bitch he has no insurance... just save his fucking life he demands. Bitch looks down upon his gunshot wound, blood gushing out, turns to her aides and tells them to roll the poor bastard back out of the hospital.

Yes, love that US healthcare system.

We are experiencing some difficulties with our wait times, but you can thank abuse of our system by unruly citizens for that, specifically immigrants who shouldn't even have the healthcare coverage they do. Our system works on a basis of severity... the more urgent the need, the faster the individual is bumped up... NOT based upon the size of the fucker's bank account.

That is not how it works in the US. The only people that jump the line for operating rooms are emergencies. I know this for a fact because I have needed surgery here in the US, have never been rich, and have never waited more than a few days.

The only people that think the US system is bad are the idiots that think your system is better despite the fact that every part of our system scores higher than yours.

 

[Oddball]

Those are politicians, not bureaucrats...They remain no matter who gets elected....Please read for comprehension.

And you can feel free knock it off with the large text any time, jackwad.

... and just who do you think the 'bureaucrats' answer to?

Nobody...That's the point.

 

[Flopper]

Intermountain, of course, is just one example of using delivery system innovations to improve the value of health services. Other integrated health systems around the country that are known for providing high quality care at lower-than-average costs offer even more perspective on what works.

The Cleveland Clinic has organized into a continuum of care delivery model: it has a tiered system in which a regional network of providers works in concert to provide a level of care appropriate to the patient's needs. But how is care coordinated and how are transitions between clinics/hospitals/etc made seamless?

Our electronic medical record system and Critical Care Transport services tie all of these tiers together. Whether the patient is being treated at Main Campus or a suburban hospital, doctors and nurses have immediate access to the individual’s complete medical record, including but not limited to medications, x-rays, test results, and prior physi- cians’ notes. This EMR system not only reduces duplication of effort, it also ensures that the treating physician has a comprehensive view of the patient’s medical history. Currently, more than six million patients use our EMR system. Our Internet site (www.my.clevelandclinic.org) is the most-visited hospital website in America, allowing patients to make appointments and even view relevant portions of their medical records online—virtually aligning all of our locations and providing immediate access to patient records.

Or look at some of the payment innovations that have come out of Geisinger in Pennsylvania:

What if medical care came with a 90-day warranty?

That is what a hospital group in central Pennsylvania is trying to learn in an experiment that some experts say is a radically new way to encourage hospitals and doctors to provide high-quality care that can avoid costly mistakes.

The group, Geisinger Health System, has overhauled its approach to surgery. And 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.

Geisinger is by no means the only hospital system currently rethinking ways to better deliver care that might also reduce costs. But Geisinger’s effort is noteworthy as a distinct departure from the typical medical reimbursement system in this country, under which doctors and hospitals are paid mainly for delivering more care — not necessarily better care.

Since Geisinger began its experiment in February 2006, focusing on elective heart bypass surgery, it says patients have been less likely to return to intensive care, have spent fewer days in the hospital and are more likely to return directly to their own homes instead of a nursing home.

A bit more on the Geisinger model which, similar to Intermountain and the Cleveland clinic, is based on access to and use of data/information (e.g. using electronic medical records or using quality measurement to gauge performance), adherence to evidence-based processes (see the "ProvenCare" protocols), patient-centeredness, and payment that transfers some risk (and accountability) to the provider:

The Geisinger system, serving an area of Pennsylvania whose economy depends on coal mines and a nearby jail, has shaken up traditional healthcare practices with innovations considered radical in this antiquated medical system.

For one, all records are electronic, meaning that doctors can immediately see what tests have been done, reducing double-ups and delays. The hospital’s website allows customers to book their own appointments, leading to 95 per cent attendance, compared with a 60 per cent show-up rate if receptionists book a time for the patient.

“Telenurses” answer calls 24 hours a day, advising patients when they should come in and when they should take some painkillers and stay at home, and they monitor people who have been discharged, reducing readmission rates.

Most ground-breaking of all, the financial paradigm of American healthcare has been turned on its head. The 650-plus doctors at Geisinger are salaried, with 20 per cent of their packages in bonuses awarded for quality, rather than the number of patients they treat. This is a stark change from the practices at most hospitals, where doctors are paid a fee for each treatment, making it worth their while to do more tests and procedures.

“If my patients have fewer complications, I get paid more,” says Kimberly Skelding, the cardiac surgeon checking Mr Schankweiler’s arteries. “Most doctors are given incentives to do more, but we’re sort of working to put ourselves out of business.”

Geisinger has developed “ProvenCare” protocols that lay out the tests and examinations a patient should go through to be treated. For Mr Schankweiler, that meant Dr Skelding had to take 40 steps before she opened the vein in his wrist.

“A lot of the steps are not things that most other doctors would do because they might not have an impact today,” Dr Skelding says, saying she checked his lipid levels and haemoglobins as part of the 40-step process.

Heart failure is the number one cause of hospital admission in the US.

Geisinger’s procedures have produced tangible results. For example, a coronary artery bypass graft operation requires an average hospital stay of 5.3 days at Geisinger and costs $88,000, compared with a Pennsylvania average of 5.8 days and $112,000.

The Mayo Clinic actually has its own Center for Innovation aimed at exploring new delivery models and "using a patient-centered focus to transform the experience and delivery of health care for patients everywhere." One of the initiatives they helped to launch recently was a variant of the patient-centered medical home model in one of Mayo's medical centers:

Begun in 2009 and 2010, the continuing project involves a broad spectrum of Austin’s citizens including the Austin Medical Center and local businesses, schools, the faith community, the Mower County Public Health department, United Way and other social services, to develop a “patient-centered medical home” model for Austin that could potentially be replicated around the United States.

The “patient-centered medical home” (PCMH) or “medical home” is a health care model promoted by some health care advocates that stresses forming long-term relationships between primary care physicians, patients and sometimes their families, as well as integration of care across all the potentially health-supporting services available in a community. Those might include elder care programs at churches, temples and mosques, exercise classes at the Y, health education classes in schools, corporate wellness programs, and so on.

A medical home pilot project at the Austin Medical Center was certified last year by the Minnesota Department of Health. The project is designed to test new ways to meet an especially thorny health care challenge: coordinating care for patients with complex chronic conditions. Forty patients and a half-dozen primary care physicians are enrolled in the project, one of 47 state-certified medical home initiatives in Minnesota. Certification allows institutions to bill for Medicaid reimbursements although in Austin’s case, not anywhere near the cost of service.

To anyone familiar with the health care reforms being implemented now, these concepts won't be new; however, they do offer clues as to what a high-performing, high-value health system would look like and thus what reform should encourage if we want to contain costs without compromising quality.

I think the best and most economical healthcare comes from an integrated systems such as Intermountain Healthcare. A system in which primary care doctors, specialist and other healthcare professionals work for the same organization offers tremendous opportunities for cost reductions and improved patient care. I am familiarly with one such organization. Your primary care doctor is the focus of your medical care. When you go to see the doctor, the computer beside him has the result of all test you have had, all prescriptions from all doctors, notes, and diagnosis. If you have a potentially serious problem, the primary care arranges for tests and refers you to a required specialist if needed. You don't get a prescription, referral, or test every time you go to the doctor. They do what is needed not necessarily what the patient wants. That's not usually the case with doctors that have private practices. If the patient doesn't get what he wants, he finds another doctor. So the patient gets a bunch prescriptions, referrals, and tests often for ailments that would resolve themself with little or no medical care.