Thursday, August 13, 2009

Better (and less expensive) healthcare

Lost in much of the current healthcare debate is discussion about ways to actually improve patient care while lowering costs. Instead the crazies focus on "death panels" and taxes and the government taking over healthcare, while those supporting reform have gotten dragged down into defending against those arguments.

Atul Gawande and three other doctors have been looking at communities around the country that already provide great care at a cost much lower than the national average:

Yet in studying communities all over America, not just a few unusual corners, we have found evidence that more effective, lower-cost care is possible.

To find models of success, we searched among our country’s 306 Hospital Referral Regions, as defined by the Dartmouth Atlas of Health Care, for “positive outliers.” Our criteria were simple: find regions with per capita Medicare costs that are low or markedly declining in rank and where federal measures of quality are above average. In the end, 74 regions passed our test.

So we invited physicians, hospital executives and local leaders from 10 of these regions to a meeting in Washington so they could explain how they do what they do. They came from towns big and small, urban and rural, North and South, East and West. Here’s the list: Asheville, N.C.; Cedar Rapids, Iowa; Everett, Wash.; La Crosse, Wis.; Portland, Me.; Richmond, Va.; Sacramento; Sayre, Pa.; Temple, Tex.; and Tallahassee, Fla., which, despite not ranking above the 50th percentile in terms of quality, has made such great recent strides in both costs and quality that we thought it had something to teach us.

If the rest of America could achieve the performances of regions like these, our health care cost crisis would be over. Their quality scores are well above average. Yet they spend more than $1,500 (16 percent) less per Medicare patient than the national average and have a slower real annual growth rate (3 percent versus 3.5 percent nationwide).

The op-ed can be found here. Gawande also wrote a great article on this topic for The New Yorker which I blogged about here.

ONE DOCTOR RESPONDED to a conversation taking place over on The Daily Dish; he points out that in our current system, there are no incentives to keep costs down even while taking excellent care of patients:

The story of $15,000 for a needle in a thigh touches a nerve with me. As a surgeon, I'd have tried to find it using local anesthetic, in my office, before escalating to an operating room. With luck -- and since it was an insulin needle it couldn't have been very deep and would have been near the entry hole -- it'd have been a couple hundred bucks or so, including my fee and the use of a few sterile instruments. It's possible, of course, that it would end up requiring xray guidance; even then, it's hard to figure where the $15,000 went.

But here's the thing: no one would have recognized the savings, or even cared, much less rewarded me for it in any way....

Likewise, when I did breast biopsies in my office, with local anesthesia and comfortable patients, happy at not having to go through the hassles of surgery at a hospital or surgery center, I saved thousands of dollars each of the many hundreds of times I did it. Again: no recognition, no reward. I just did it because it seems right.

This is part of what gets lost in the screaming rhetoric of the right, the death panels of Palin. Some doctors know how to save the system lots of money, and do so, every day. Establishing a means to discover them and to spread their wisdom is central, as I understand it anyway, to Obama's plan. Not rationing. Discovering why some methods are more successful and less expensive than others. Hard to understand, maybe; and very easy to demagogue. Which is exactly the problem.

His comments appeared in this post; he was responding, as did many others, to this one.

FINALLY, ON THE SUBJECT OF THE SO-CALLED DEATH PANEL: Obviously creating such a body would be a bad idea. Yet Americans do need to have a rationale conversation about what makes sense in terms of taking care of those we love at the end of their lives.

If you had a contractor scheduled to install $5,000 of new tile in your upstairs bathroom, you might just tell him not to bother if most of the first floor was on fire.

And if you rolled back the clock to when most of our grandparents were children, they probably had a much healthier relationship with the idea of death. Going back even further, it was pretty likely that people were raised in homes with multiple generations living (and dying) under one roof. Birth, death, and everything in between: it was all part of experiencing life.

Now we live mostly on our own--single people, couples, or parents and kids defining the household. Death happens, more often now, at a distance. And I think one factor that underlies people's willingness to do anything--and spend any amount--when a loved one, especially a parent, is dying may be a sense of guilt that we weren't there for them earlier. I'm painting with a very broad brush, and everyone's story is different. But it just makes no sense to me when people want to put Grandma through some difficult treatment that is unlikely to significantly extend her life and just may make her more uncomfortable during the time she has left.

The conversation isn't about whether someone else should be deciding on when to pull the plug on Grandma. The conversation should be one with Grandma... finding out just what she wants. And now, while she's still relatively healthy.

The conversation should be about what the incentives in our healthcare system should be, because right now they're set up to reward doctors and facilities that order more tests and perform more procedures rather than those who provide their patients with a higher quality of life.

And I want a way to have my personal preference--which is to not have extraordinary measures taken to keep me alive for a mere few months--mean something when it comes to the cost of my own health insurance. If I don't want replacement value insurance coverage on my car, I don't have to pay for it. I want the ability to buy a health insurance policy that will take care of me while I'm alive, not to keep me breathing indefinitely in my deathbed.

A few months ago, there was a great program on Fresh Air about this topic; you can listen here and read my earlier comments here.

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