De­bate over debt is needed, but let’s see how re­forms play out

Modern Healthcare - - Front Page - DAVID MAY As­sis­tant Man­ag­ing Edi­tor/Fea­tures

Dead on ar­rival. Dead shortly af­ter ar­rival. Those de­scrip­tions cer­tainly ap­ply to a cou­ple of thought-pro­vok­ing—and alarm­ing—re­ports con­cern­ing the U.S. health­care sys­tem re­leased in the past few weeks. Based on early re­ac­tion to the ini­tial draft of rec­om­men­da­tions from the bi­par­ti­san panel charged with at­tack­ing the bal­loon­ing na­tional debt, that thump­ing noise you heard was from the letters D.O.A. be­ing rub­ber­stamped on the doc­u­ment by pun­dits and ob­servers, in­clud­ing mem­bers of Congress. It looks as if there’s some­thing in the draft to be de­spised from all an­gles, no mat­ter what sec­tor of the econ­omy and what your po­lit­i­cal per­sua­sion. Tax in­creases, So­cial Se­cu­rity changes, de­fense cuts, ben­e­fit eliminations. What some find pop­u­lar oth­ers will deem anath­ema.

The doc­u­ment re­leased Nov. 10 was only the first round of pro­pos­als from the Na­tional Com­mis­sion on Fis­cal Re­spon­si­bil­ity and Re­form. This one was penned by the panel’s co-chair­men, and health­care cer­tainly didn’t es­cape the ax. Of course, since the in­dus­try ac­counts for 16% of gross do­mes­tic prod­uct, it will al­ways be sub­jected to in­tense scru­tiny.

Given the fact that the nation’s to­tal debt stands at just un­der $14 tril­lion and climb­ing, it’s cer­tainly time to start hav­ing a na­tional dis­cus­sion about how to stop the bleed­ing.

But when it comes to health­care, this coun­try just had that pleas­ant dis­cus­sion—in the ramp-up to pas­sage of the Pa­tient Pro­tec­tion and Af­ford­able Care Act in March. Re­mem­ber that the law will pro­vide in­surance cov­er­age for 32 mil­lion unin­sured Amer­i­cans but still slow the growth rates in fed­eral health­care pro­grams over time.

While the law is im­per­fect and clearly doesn’t do enough to bend the cost curve, it has promis­ing re­im­burse­ment re­form ideas that de­serve to be tested broadly be­fore new sweep­ing changes are con­sid­ered. Those con­cepts in­clude bun­dled pay­ments, ac­count­able care or­ga­ni­za­tions and med­i­cal-home mod­els, among oth­ers.

Pro­vi­sions boost­ing com­par­a­tive-ef­fec­tive­ness re­search can’t be overem­pha­sized be­cause that’s the type of data that could help to ul­ti­mately slash health­care spend­ing. Crit­ics scream bloody murder—that it will lead to ra­tioning. Of course it will, if done cor­rectly. And that’s just what this coun­try needs and ac­tu­ally is what the bi­par­ti­san com­mis­sion rec­om­mends. But we’re not talk­ing de­nial of pa­tient care what­so­ever. What re­ally needs to be ra­tioned is the in­ef­fec­tive, in­ap­pro­pri­ate and un­nec­es­sary health­care that has been driv­ing the cost spi­ral for decades.

That was ap­par­ent once again in a re­port re­leased last week by HHS’ in­spec­tor gen­eral’s of­fice look­ing at the in­ci­dence and cost of “ad­verse events” at hos­pi­tals. Be­cause of such events, not long af­ter ar­rival at a hos­pi­tal, pa­tients are suf­fer­ing se­ri­ous harm and, in too many cases, they pay with their lives—of­ten as a re­sult of a con­di­tion not present at ad­mis­sion.

The study looked at 2008 data in­volv­ing Medi­care ben­e­fi­cia­ries, de­ter­min­ing that 13.5% of those pa­tients ex­pe­ri­enced ad­verse events dur­ing their hos­pi­tal stays. Not all of the events were con­sid­ered pre­ventable, but nearly half of them (44%) were. The ex­tra cost to Medi­care was es­ti­mated at $324 mil­lion in one month alone, which ex­trap­o­lates to $4.4 bil­lion in ex­tra spend­ing on an an­nual ba­sis. Think of the cu­mu­la­tive sav­ings to the na­tional trea­sury if such un­nec­es­sary care could be elim­i­nated across the en­tire health­care spec­trum.

The Af­ford­able Care Act in­cludes a pro­vi­sion that pe­nal­ize hos­pi­tals even more if they rise above cer­tain thresh­olds for hos­pi­tal-acquired con­di­tions. We’re not talk­ing big money here, but it’s an­other way to re­in­force that tax­pay­ers aren’t go­ing to keep pay­ing for poor-qual­ity care.

That pro­vi­sion doesn’t kick in un­til fis­cal 2015. Maybe it’s time to speed up the timetable on such penal­ties. Add hos­pi­tal-acquired con­di­tions to the list where more ra­tioning can’t ar­rive soon enough.

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