My friend Josh Freeman offers his take on an article published in New England Journal regarding “Value-based purchasing” in health care. In this study, hospitals were paid a little more (about 2%) if they did some simple things effectively (made sure most patients got the right medications and correct instructions upon discharge). I personally don’t think the study proved much of anything. The study coincided too much with actions initiated in the same time period by the Joint Commission that required hospitals to do these things to maintain accreditation. In effect, the small “carrot” provided by the feds was overwhelmed by the larger “stick” that is the JC leading to an expensive flop of a study.
Josh makes a very good point, however, in that the “value” being purchased was not necessarily seen as valuable by patients. The hospitals were being asked to do things that lead to shorter hospital stays, not necessarily to folks feeling better. This reflects the continued disconnect between the purchasers of health care (insurance companies, governments) and the owners of the bodies, minds, and souls upon which health care is foisted (sick people).
Part of the problem with this study is that for a health care interaction to occur in America today, someone has to be sick. Over half of Americans spend under $300 annually on “health care.” I suspect that they make food choices which may lead to obesity and exacerbate diabetes. I suspect they consider reducing risky behavior such as smoking or physical inactivity as well as mitigating other genetic risks. I suspect they make decisions on how to spend leisure time, perhaps debating whether or not to focus on activities which would improve their spiritual and emotional wellbeing. Unless they walk into a pharmacy or a physician’s office, however, it doesn’t count as health care. The health care industry under the current payment structure will have to be content to wait on the sidelines until the person becomes gravely ill then spring into action, making sure that they get the right medicine at the right time in the right (expensive) place.To maintain the health care economic engine (18% of our gross domestic product), it requires a lot of decisions leading up to “Oh my God, I think I’m having a heart attack!”
This leads me to the Center for Health Quality and Payment Reform and Harold Miller. I saw Dr Miller’s presentation this weekend and was amazed. Many people think that the only way our country can extract ourselves from this mess is a single payer, Medicare for all system. While we may see this, I don’t think a country that enjoys 100 different varieties of ketchup will agree to a single flavor of health care. Dr Miller offers a blueprint for moving away from the current “volume based” strategy that rewards getting people really sick and then snatching them (VERY EFFICIENTLY) from the jaws of death, instead moving towards a place where the money follows the person and he or she can determine what values should be emphasized. Both traditional and non-traditional means could be used to in this system to encourage wellness rather than focus on illness. The vehicle, Accountable Care Organizations, exist today as a consequence of “ObamaCare” and people are starting to take notice. What will we ever do with all those empty hospital beds?