The goverment will proclaim that the failure of hospital ED’s is merely proof that a free market is unable to produce institutions which can care for the people.

We will also discover that the Cuban model is indeed a breakthrough in medicine. Most people will be treated by a NewDoctor having 6 months of intense medical training, paid directly by the government.

People on the Govt/Union health plan may see NewDoctors who have graduated to the Laureate program, merely a technicality.

Black market medicine will be severely punished as a scheme to divert needed medical resources from the masses.

jeff.thompsonMD@hca.wa.gov

Behavior will not change without some skin in the game. Charging Medicaid beneficiaries a copay, even a nominal one, would curb some of the most egregious abuse.

As soon as I read the first paragraph, my first thought was: how does one measure value in an institution of higher learning? Never mind, you answered the question a few lines down…it would be very, very difficult if not impossible to do.

Wade Kartchner

“Your poll questions are misguided, and do not represent a matrix that can determine “quality”. Quality medical care involves providing accurate and up to date advice and counseling to a patient that is individualized to their particular set of circumstances–physical, emotional, psychological, and financial, such that they may make an informed decision about how to go forward with their medical care and health maintenance. When patients make poor decisions, it may be necessary to understand what makes them “tick”, in order to help them arrive at a more “logical” decision. But we must understand patients do not always make “logical” decisions, nor do they often make “good” decisions.

You can expect physicians to stay current in their field, but you can not measure quality easily, affordably, or, with current resources, accurately. Currently, the milieu is to expect high quality care, that is cheap, and fast. You’ve heard the adage before that you can have two, but not all three, simultaneously. Anything else is a compromise–and the VALUE in that compromise is best determined by the PATIENT, whom we serve (and NOT by industry and the government, who can not, by definition above, determine what represents quality and value to EACH INDIVIDUAL patient). Unfortunately, even if you survey patients, it would be hard for them to determine if they received “quality” care–as sometimes, that care might involve recommendations that are opposite of the patient’s wishes, despite being in their best interest. The performance of things in the patient’s best interest is one of the criteria for “professionalism”– try measuring that!

Since quality and value to the individual patient can not be reasonably quantitatively assessed by administrative bodies such as insurance companies and government agencies, and yet, as payers they want to somehow ensure quality and value–the Heisenberg uncertainty principle is invoked–their efforts to obtain and quantify the data affects and invalidates the results. I suppose insurance companies and government agencies need to divest themselves of such an interest, and not interfere as third parties anymore, between the only two parties who should be interested–the patient, and the physician.

It is noble for them to want to raise the floor on quality and value–but for all those attempts, and those being considered for the future, they are also succeeding in lowering the apex, as well.

Sad.”

I sometimes think the best approach is to just go to the doctor when we feel sick. Preventive medicine does have a place, particularly in high risk patients. But, what about the low risk patient who has a breast biopsy because of a benign appearing abnormality on mammogram, develops a hematoma which then becomes infected, requiring further surgery, then develops a DVT and dies of a pulmonary embolus?

I learn a great deal from your writing, Dr P. Your points are fresh to me. Your platform is a great opportunity for non-partisan education.

The injection of anti-gov key-words (eg, bureaucrat, “arbitrary” pay-for-performance) and demonizing of the *other* high-minded makes it hard for subsidized-coverage proponents to concede ground, though.

I like your writing. I’m going to send my friends, but with a disclaimer.

Chris

But, here the HHS has ultimate faith that hospitals will find a way to save money while delivering the same excellent care, by appealing to the crass nature of doctors and hospitals to do anything for money. They are sure you can do better. All they have to do is threaten your income. I wonder how far they can go with that.

I suggest that each hospital do readmission triage: Unlikely, Maybe, Probably.
Maybe and Probably: Schedule a readmission for 28 days, and cancel it if not needed. If they are readmitted at any time, mark it as expected, so not subject to the readmission limits. Explanation: We knew they would be readmitted, but it was clearly cheaper to let them walk around for a few days than remain in an expensive hospital bed or hallway until they relapsed.

For Unlikely: I suggest that hospitals partner with each other, so that no one is readmitted to the same hospital within 30 days. They have to go to some other hospital. There should be few of these, as their readmission is unlikely. With electronic medical records, it would be easy to transmit the patient history to the cooperating hospital, and the patient would automatically get a second opinion.

Medical costs would go up with all the extra paperwork, but it is better than losing 1-3% in revenue.

Sorry to say, if they are readmitted because they still have an IV or catheter inserted, you will have to take the hit.

Add to that list you do not want to be the first physician to be sued for fraud because they did not know the difference between a macaw and a parrot?

Will there be a different code for someone killed or injured in a declared war vs an undeclared war?

This could be taken to a ridiculuous extreme if we are not careful. Oh, wait, it already has been.

It would appear to me that regardless of the political landscape, Health Insurers are extremely profitable and I believe are behind much of the legislation seen at the state and local level.(which always seems to benefit them). So why would the powerful insurance industry let us go down the road of a single payer system?Specifically, how would this benefit them?

There is no question that Goodhart’s law comes into play whenever you base a reward on a parameter; the implication being that true “quality” and the measured values of parameter itself immediately part company. Nothing in my discussion of P4P should cast any doubt on that. However the results of the British studies suggest than there is even more going on.

If doctors were really motivated by the (sometimes) huge sums being thrown their way, why didn’t the measured parameters themselves go up? True, Goodhart’s law says that a measured increase would say nothing about any improvements in “quality”, but one reason for this is that people are incentivized to raise the parameter value by any means available. They “teach to the test”. This might include throwing non-compliant patients out of their practice, continuing to take BP measurements until they get one they like, or a host of other strategies. Curiously this did not appear to happen in the British studies. The parameters in question did not rise. They did nothing other than follow the trends that had already been established. Why?

There are several possible explanations. The first, which was proposed by the authors themselves, was that the parameter values were set too low. Therefore most all clinicians achieved them easily and had no incentive to do a darned thing. Maybe. A more likely scenario in my opinion is that the clinicians in question were already doing pretty much everything they reasonably could to optimize the treatment of their patients. In this case the P4P incentive or punishment could have been anything, but aside from simply cheating it is unlikely that the docs could do anything to improve the measured parameter. After all, to a large degree clinical outcomes are completely out of any provider’s hands. Patients can be non-compliant. Diseases can be resistant to treatment. Generic drugs can lack potency. Basically anything can happen, and it apparently never occurs to our non-medical administrative Leaders that perhaps the great majority of providers are simply doing the best they can, all day every day.

At any rate, this result led me to consider that P4P might not just be invalid as a result of Goodhart’s law, but frankly ineffective (or even counterproductive) in the medical setting. This has some serious implications for whole systems of healthcare incentives such as ACOs and medical homes, whose entire reimbursement is likely to be dependent upon dealing with P4P all day, every day, and in a great majority of their cases. As it happens, there is good experimental evidence that this is the case, and we’ll present in in the next installment.

Thanks so much for your blog as well, Dr. Gaulte. You frequently pick up on interesting news and finding much quicker than I. Reading about them there always makes for an interesting day.

The push for health care reform is motivated by our current financial disaster from all government promises. Congress has promised Medicare, Medicaid, Prescription Drug, and Social Security benefits over the next 75 years that are underfunded by $88.6 trillion ($88,600 billion) in current dollars. Our entire current yearly production is about $15 trillion.

The public discussion is about the burden of $1 trillion ($1,000 billion) in extra taxes over 10 years. The true shortfall is 12 times as much, more than $1 trillion per year.

The Democratic “solution” to this political and economic problem is to put everyone into one medical care pot. We then all get equal amounts of services at whatever high tax rate the government can levy. The young must be coerced into this system, to extract as much money as possible to serve the old.

Our politicians want to obscure their part in this disaster. Or, at least delay the day of reckoning until they can leave office with more money. Even if this makes the eventual collapse much worse.

Obamacare Bails Out Medicare

Joke: We lose money on every patient, but we plan to make it up on volume.

I think this is funny, but ObamaCare proposes it as a plan.

The housing and financial collapse was a $3-4 trillion loss to the economy. An underfunding of $88 trillion is unimaginable.

I got that it’s a zero-sum game, and that all that can happen is that there’s $15M less MC $ to spend now, and access to care is supposed to be a primary goal.

Got another 30 days to decide to opt-out or not….

http://online.wsj.com/article/SB118101135977724637.html#articleTabs=article

Republican senators can’t issue subpeonas on their own. Soon, the Republican majority House will be able to investigate whatever they wish. Maybe they can investigate Berwick as a favor to the Senate.