Next on Obamacare
by Greg Scandlen
Issue 219– January 16, 2013
Two days after the election, the Institute for Health Improvement held a conference to discuss where the health system goes from here. Among the 100 invitees were former Senate majority leaders Tom Daschle and Bill Frist, so you know it was pretty high-powered.
In the write-up of the conference the sense of both urgency and opportunity was palpable. (You can get a copy by going to Berwick’s Health Affairs blog post on it and then following the links and registering with IHI.) But the discussion is also disturbing and sobering.
There isn’t much question that the participants are hands-on experts at running hospitals, physician groups, health plans and the like. They know the ropes. They know the challenges. But, still, they are allowing fine rhetoric and political optimism (read “hope and change”) to blind them to reality.
First, they seem quite relieved the election turned out the way it did. The “tremendous confusion, even trepidation” is over, and the page has been turned. The report says the participants “predicted with startling unanimity that time is running out to save American health care from blunt cost cutting that would put the health of patients at risk.”
They also fully expect “significant cuts to reimbursement” in the very near future, but seem to welcome the cuts as a way to force better coordination of care and they believe physicians are now more willing to “collaborate” with management, especially on the dual goals of bundled payments and transparency. And here is the first contradiction.
No one seemed to consider that bundled payments and transparency actually work against each other. I won’t quite say they are mutually exclusive, but getting close. Transparency is relatively easy in a fee-for-service setting — we did X and got paid Y. It is relatively easy to see how the patient responded to the particular treatment.
But a transparent bundled package of services would require knowledge of what was in the bundle and whether the bundle was appropriate for the patient’s needs. It is hard to look inside the bundle to determine if every discrete element was delivered competently (or at all) by a qualified professional. “Bundling,” while not a bad idea in itself, raises a host of questions.
Will every group use the same bundle? How can a payer tell that the bundle in Facility X is the same as the bundle in Facility Y. If not, should the payment be the same for both bundles? What if there is something in the bundle that is inappropriate for a particular patient or group of patients? Will it be delivered anyway? If not, who determines what to remove? Does that removal affect the payment? Can the bundle be quickly revised as more experience is gained or must a revision be approved by payers or the government? The process of bundling seems to hide information rather than expose it.
“Transparency” is similarly more complex than it would seem at first. Transparency of what and to whom? In what form will the newly transparent information be presented? How can transparency and privacy be reconciled? Are there liability protections for providers who are required to be more transparent?
Both “transparency” and “bundling” seem to have become some of those feel-good, catch-all phrases that mean very different things to different observers. Each of us assumes that they mean the same things to other people as they do to us. In that sense they are like “quality” — impossible to oppose, but also impossible to define.
None of this seems to have been discussed at the conference, but never mind, they rush on to other considerations, including a new “Grand Bargain” between the federal government and provider organizations.
The write-up explains it thusly −
– First, there will be cost cuts;
– Second, government will loosen regulations to give provider organizations more room to innovate on health care delivery in response to lower revenues;
– Third, to guard against foul play in a looser regulatory environment, providers will be required to be more transparent than ever before about the prices, processes, and outcomes of care.
The provider representatives spoke at length about the burden of regulations on their current practices and their ability to innovate. The regulators (in this case, Don Berwick and Tom Daschle) argued that providers’ bad behavior brought on the regulations. All hoped that greater transparency would do the trick.
But it is hard to see how. Transparency might help to reveal this bad behavior, but that would simply trigger regulatory intervention. Indeed, it is hard to imagine many regulators who would be content to simply punish bad behavior rather than preventing it from ever happening.
In any case, this “bargain” quickly devolved into a who-goes-first question. If innovation requires fewer regulations, will the regulators back off in the hope that these innovations will happen? Or will they insist on maintaining the regulations until the innovations are proven? I think I know that answer to that. And once again, “transparency” is being used as a talisman that really has no common meaning.
In any case, you get the drift. Curiously absent was any discussion of how patients feel about any of this. Yet it is the patient/taxpayer who ultimately pays for all of this and is the sole reason any of these people have a job in the first place.
And it is only the patient who can make change happen. The existing health care establishment is incapable of reforming itself. This establishment includes both the people providing the services and the people regulating them. Not one of them will admit that what they do may be worthless. Each thinks that what THEY do is essential and they could do it better if only it weren’t for those other guys.
So, as the Titanic sinks into the frigid Atlantic, all the crew will be pointing fingers and blaming someone else for the disaster. I hope you have your own personal lifeboat ready.
Greg Scandlen blogs at Policy Updates for the National Center for Policy Analysis, where this first appeared.