A common criticism of the U.S. healthcare system is that we spend too much on treating sickness and not enough on staying healthy. The idea is that a greater emphasis on wellness and prevention will lead to a healthier population and cost less than our current system.

There are huge benefits to having a healthier population – improved quality of life, increased productivity, and longer life expectancy to name three. There also are immediate financial returns to better health, particularly for the private sector. The Milken Institute , an economic think tank, estimates that more than 109 million Americans have at least one chronic disease for which the cost – measured in terms of the total impact on the economy – is $1.3 trillion annually. Of that, $277 billion is spent on direct treatment. The remaining 80 percent is lost economic productivity. Even a modest improvement in health would make a major difference to the Medicaid program, employers’ healthcare costs, and workforce productivity.

What would it take to accomplish this? According to the Milken study, 40 million cases of chronic illness could be delayed through lower rates of obesity, continued reductions in smoking, a decline in alcohol consumption, increased physical activity, bringing cholesterol rates down to their 2000 levels, improved air quality, a gradual decline in illicit drug use, and a modest improvement in early intervention and treatment. Read more…

We want to control healthcare spending and improve the quality of the care delivered at the same time – the challenge is how to do it. The Chief of Surgery at MGH recently sent out a departmental email describing what he called “always events” that pertain to inpatient care.

• Always record an accurate list of the patient’s prior medications within 24 hours of admission.
• Practice appropriate hand hygiene using Cal Stat, an alcohol based skin cleanser before entering a patient’s room and after leaving it – every time.
• Always use an electronic medical record and electronic prescriptions to document patient care.
• When discharging a patient from the hospital to a non-acute care facility, always give the next provider a full set of critical information about that patient (we have defined a minimum of seven agreed-upon elements that should be communicated).

We don’t do all of these things 100% of the time yet, but by setting the goal at always, Dr Warshaw has defined a clear target. Read more…

There is a new term in the lexicon of quality and safety that refers to errors in medical care that are “clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility” (definition by the National Quality Forum). The term is never events. The idea is that certain events should never happen in hospitals and that establishing a zero tolerance for these problems and requiring public reporting will help eradicate them. Another related idea is that economic disincentives will help reduce the incidence of “botched hospitalizations,” a commonly used term for the never event concept. In a recently released, 2,000-page report, Medicare announced it will not pay hospitals for the care needed to treat patients after certain preventable medical complications. The concept is that non-payment removes the financial “reward” that currently comes with complications and will get complacent doctors and hospitals to make more of an effort to improve.

The problem is that some the events on the list really are “never events” (like wrong site or wrong patient surgery) that can and should be eliminated. But the other end of the spectrum includes conditions that may never be eliminated, although having zero as a goal is a worthy aspiration. An example of this latter category is mediastinitis, a hospital-acquired infection involving the sternum or breastbone that can occur after heart surgery. The only way there will ever be a zero incidence of mediastinitis is if heart surgery were to become obsolete or some sort of fundamental breakthrough in infection control were to occur. Read more…

About every six months, our local media carry some version of this story about Massachusetts healthcare costs, and explain that the problem is we have too many doctors, and that no one is doing enough to control costs. Just this last month, the Commonhealth blog reiterated this claim via a guest contributor as did reports on healthcare from the New England Healthcare Institute and the Boston Foundation.

The label is both facile and inaccurate. Two of the “costs” that are included in the numbers that appear so inflated are the costs of doing research and the costs of caring for out-of-state patients, both activities that bring with them substantial revenue. By any rational criteria these are not a burden but among the benefits of having some of the best hospitals in the country. To label ours as the world’s costliest health care you must calculate that the extraordinary level of funding that Massachusetts receives from the National Institutes of Health is a health care cost and that together with the care we provide to out-of-state and international patients – who often pay the highest rates for that care – these funds are a drain on the Commonwealth’s economy. They plainly aren’t. Life sciences research and out-of-state and international patient care are key elements of the health care economic engine that sustains this Commonwealth in rough economic times and employs 14 percent of our workforce.

Insurance premiums are a better measure of healthcare costs than hospital expenditures. Read more…

Economic theory states that having insurance – of any kind – can change the behavior of the person being insured. This is known as “moral hazard,” a theory that has driven American health policy for most of our lifetimes. Moral hazard comes in many forms; spending someone else’s money is just not the same as spending your own. How many fewer $200 hotel rooms would there be without business expense accounts? With budgets in the billions, this is how the Pentagon ends up with the infamous $640 toilet seat.

When it comes to healthcare, proponents of moral hazard fear that, absent a financial stake, patients will demand more expensive and unnecessary tests and treatments. They argue that a “brake” on this demand is needed to assure efficient consumption of healthcare. It’s one of the reasons co-payments, deductibles, and the notion of “skin in the game” are solidly entrenched in our health care system and the reason why we’re likely to see more cost sharing in the name of consumer-driven healthcare.

But how does economic self-interest affect health care consumption? Read more…

Most of the attention given to Massachusetts health reform has focused on insuring the uninsured. That’s appropriate, since the first priority of this new law is to get as close to universal coverage as possible. Two elements of reform that deserve some attention, however, are the new Cost and Quality Council and the provision that conditions payment increases on performance reporting. This is all part of the larger national drive toward a “transparent” health care system, a concept which is the cornerstone of an executive order signed by President Bush last August that many commentators expect will finally tame healthcare costs.

Proponents of healthcare transparency contend that outcomes report cards will drive market reform via informed consumer choice – educated patients with some of their own money at risk will seek out the best value in healthcare at the lowest cost if provided with detailed cost and outcomes data along the lines of a healthcare “Consumer Reports.” A fine theory and a worthy goal: the unfortunate problem is that producing an effective consumer report is easier said than done. Read more…

It is increasingly clear that to really improve our nation’s health status requires more attention to chronic illness, prevention and wellness. Providing routine acute care is not sufficient. And for health care reform to succeed in Massachusetts, we need more of that comprehensive primary care. Access to routine primary care is already an issue in Massachusetts so, if health reform is to meet expectations, this problem needs to be solved.

Finding a primary care physician (PCP) who is accepting new patients these days is a challenge. Even when a PCP is located, the average waiting time for a new patient appointment is nearly five weeks. And it’s not just a local problem. The American College of Physicians recently warned that “primary care, the backbone of the nation’s health care system, is at grave risk of collapse.” The culprits: growing demand for primary care, and fewer physicians selecting careers in primary care.

The supply side of the problem is a complicated one. Read more…

The cost of healthcare is a major problem and getting worse, as demand for healthcare services grows relentlessly. Some believe that direct to consumer advertising of costly drugs and tests is the problem. Others think that containing demand by forcing people to pay more out of pocket for their health care expenses is the way to reduce costs. But to me, the real crux of the cost problem isn’t pharmaceutical advertising or recreational MRIs. The highest costs by far are generated by people with chronic illnesses who need lots of medical care. Kenneth Thorpe, a professor at Emory University, has created a great chart to illustrate this problem. Using data from the Medical Expenditure Panel Survey (MEPS), he has shown that 20 percent of the population account for 78 percent of health spending and 30 percent generate almost no costs at all.

That the sickest people consume a disproportionate share of our country’s health care resources leads to two important conclusions. Read more…

From a doctor’s perspective it is exciting to see the Massachusetts health care reform law being implemented and all the smart and capable people who have been enlisted into the effort. The changes that are visible at the front lines of healthcare delivery are subtle and will take time to have a tangible impact. Yet they are vital. Read more…