[HSF] RES: [OT?] Why should Health Purchasers pay for the cost complications?

Wed Oct 10 17:40:08 EDT 2007

Undoubtedly it will come and continue to come that large payers interject their "expertise" into the argument of cost verses value. I am just arguing that it will be inefficient, likely counter productive unless less care is the goal, and inappropriate from the patient side which we doctors are too willing to ignore in our arrogance of medical rationality (are JHW crazy in refusing blood or what?). What exactly is wrong with different approaches for educating people of different backgrounds and experience, different types of housing or transportation for different geographical populations, or having different style of practice, say, medical Rx, PCI, Off pump or on pump for a range of patients? Do we really know enough to say divergent practice is wrong? If sometimes, when not? Do you want your physician to do what the article says or what he usually does? I bet it is both DEPENDING....

We must be careful that we do not make universal or its slogan, equal, the poor sister of better but actively strive for different. Although it is a contrary opinion (which is why I bother to say it), academic Europe and the USA have gone way towards the intellectual adoration of the median, a universal world view. Nature is not consistent in its solutions, details or fairness. Should our proscriptions be like or unlike nature? Is our rationality timeless or biological in form? By mathematical definition norms are not often genius or exceptional. Maybe excellence is where you are trying to take us also, but I don't think your external control model can get us there. Transparency and choice are the best control for poor quality, not big brother or lawyers or Tea or Ani as experts. Heavy handedness in governance or asteroids entering our "biosphere" get rid of the "weak" but perhaps at a gruesome cost.

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Wednesday, October 10, 2007 9:25:23 AM
Subject: RE: [HSF] RES: [OT?] Why should Health Purchasers pay for the cost complications?

Tea

Do we not first need to teach ourselves the nature of good health care before we educate others? 

How do we educate others and expect them to believe us if we all do things so differently, have vastly different complication rates, and how a patient with the same disease can have totally different procedures depending on which doctor they see? Our refusal as a speciality to scrutinize our practices, adopt evidence base or consensus base to our practice, audit and improve our results, and modify our approach as new data emerge, is what is driving health care purchasers to the draconian measures such as not paying for complications. If we do not regulate ourselves and put our house in order, someone else will do it for us. The media is also waking up to this (see media recent articles on variation in practice of coronary revascularisation practice and also one last week in US News and World reports on scandal of patients still getting mitral valve replacements in US hospitals when repair could be performed). There will be more (purchaser driven
 regulation) to come.

Ani

> Date: Tue, 9 Oct 2007 19:17:42 -0700> From: tacuff at swbell.net> Subject: Re: [HSF] RES: [OT?] Why should Health Purchasers pay for the cost complications?> To: OpenHeart-L at lists.hsforum.com> CC: > > This discussion has taken some interesting turns as HSF always does primarily due to the exotic examples (observances) provided by the members. These tend to knock the wind out of the cockamamie and local theories that get espoused by myself and others.> > I do believe that this thread has shown how unlikely it will be that cost cutting by authorities will produce better care in the long run for more persons however seductive that logic may seem to empire builders (or empire skimmers).> > This is why I think that we (doctors) should try to teach the world, or at least those that at time to time will listen, the nature of good health care. Clearly this will also include methods to economically incent and support such care. > > This is also why I have said in
 other threads that we need to shift the conversation to value and away from cost. Saving cost or shifting cost in the macro (eg government or other big funder) has never created value in the absolute or populist sense. Value is produced on the individual level by controlling micro cost and adding value. (The first half of this previous sentence may be the only thing that Marx got right.) That this value mill took place in earnest by capitalists under the eye of economists gave the phenomena the name capitalism (and confounded Marx). The principle could be just as correctly called marginalism, since the individual(s) that control the cost to produce a margin is the same that produces new value. The Chinese have shown that small margins created by billions of creators can produce great value (the positive moniker of cost) without owning the property (China is "communist") and just controlling the margin. Ergo marginalism.> And why creation of health value
 needs to be in the hands of thousands of doctors and millions of patients and not a handful of politicians or bureaucrats.> > Thus "not paying for complications" might spur some to control complications by making better products or health care, but likely many will take a more direct path to lessening complications by avoiding the possibility largely or entirely by limiting care or programs. This will probably produce less value not more value in toto in the "marketable" place. Clearly controlling the price of gas or increasing its tax for whatever laudable reasons did not make gas more available in the Carter 1970's even if some individuals chose to drive smaller cars. > > That health care is a "controlled market" presents another set of problems, but does not invalidate the best source of new value in any "market". It is, however, another topic.> > tea> > > > ----- Original Message ----> From: Theofilo Gauze <tgauze at cardiol.br>> To:
 OpenHeart-L at lists.hsforum.com> Sent: Saturday, October 6, 2007 5:37:15 AM> Subject: [HSF] RES: [OT?] Why should Health Purchasers pay for the cost complications?> > > Dear Tea, Ed and list members,> Thinking that the solution is to cut, cut and cut only make sense in the> communist world where the masses are the rule and only the dictators are> above them. In many communist countries like Venezuela, Brasil, China and> Russia we see that this "way of death" is ahead of you as they decided to> build a monster State that rules the economy and trash individual endeavor.> Take Brasil for instance, our bigger contractor in healthcare is government> with the Unified Health System (some communist craziness) where every> "person" (doesn't even need to be legally in the country) is entitled to> almost every treatment free of charge(free to then - we tax payers are close> to over 40% net income in taxes - some say 50%). Heart surgery business are> going bankrupt
 (not to mention that almost all coronary obstructions are> suitable for stenting by our cardiologists standards and valve disease is> something to be treated clinically). This system already pay nothing for any> treatment (CABG X 3 pays some U$500 for all physicians involved and some> U$800 for all hospital expenses) and that's drives decision making of> private practice payers - just do the math. That's the end of the road you> guys are being put to walk. > Let's remember Dr.Any that being a payer to hospitals and doctors alike is> nothing but business and like any other in free market should take risks and> pay some share to be in this game. > Remember there's no excellence without money and that's the American (or> should I say the capitalist free world) way. When you deny money based on> one sided decision process the most damaged in the system is the patient. > Sorry for the tears.> Theofilo Gauze> > > > > > -----Mensagem original-----> De:
 openheart-l-bounces at lists.hsforum.com> [mailto:openheart-l-bounces at lists.hsforum.com] Em nome de Edward Bender> Enviada em: sexta-feira, 5 de outubro de 2007 18:47> Para: OpenHeart-L at lists.hsforum.com> Assunto: Re: [HSF] Why should Health Purchasers pay for the cost> ofourcomplications?> > Perhaps the same sort of negative incentives might be of value in the > VAD Business (that's Business with a capital B). Let's say that you > place a lot of VADS in very ill patients. Assume that a significant > number of these patients have a very long and expensive hospital > stay, culminating in death with a million dollar plus hospital bill. > Perhaps you should not be reimbursed for the services to that > patient. Maybe then and only then would you either stop doing these > high risk VADs (in favor of lower risk cases or ambulatory surgery) > or maybe you would try harder to prevent the death of the patient.> > This argument, like the arguments you state below,
 make no sense > except if you live in a utopian kind of economic world where the only > variables that exist are the ones that you can control.> > Ed Bender, MD> > > On Oct 4, 2007, at 2:14 PM, Ani Anyanwu wrote:> > > But that is exactly what should happen - hospitals that have high > > complication rates or that cannot figure out ways to curtail > > complications and their costs will go out of the business of > > treating high risk cases. They can focus on ambulatory surgery and > > low-risk inpatient surgery where risk of such complications is > > high. Those hospitals that can figure out ways to keep > > complications down and keep costs down when the complications occur > > will flourish. That is what happens in any other economy.> >> > It is simple. For example if you earn 5000 dollars for each > > cataract operation you do then you keep aside 100$ to cope with > > complications. If you have one infection in 500 and this costs > > $30,000 to mange
 then you are fine. If on the other hand you have > > 15 infections then you have a big financial problem. Current > > reimbursement systems allow both of these examples to be equally > > profitable even though one is doing a much worse job. This is how > > all insurance based businesses work - you keep aside some of your > > profit to deal with the setbacks.> >> > Say if you are an airline you set aside certain amount to deal with > > compensating passengers for flight cancellations and delays. The > > onus will then be on you to keep this number down to the bare > > minimum the number of cancellations and bumps (by good planning, > > equipment maintenance, efficiency, customer service etc) to > > maximize profit. You could not argue - as physicians do - that the > > costs of cancellations arising from your inefficiency or poor > > quality should be paid for by the government or customer. If you > > cannot, or refuse to keep the cancellations down, then
 you should > > not be in the business of selling air transportation - you could > > for instance sell newspapers instead where risks are low.> >> > Hal surprises me when he says he will not take one or two patients > > because of a 2% infection risk (I actually do not believe he would > > take this stance when he thinks about this more). All Hal's > > hospital needs to do is to factor the cost of treating these > > infections in their budget (just like they factor unforeseen legal > > costs for example). Hal is actually a beneficiary of these market > > forces even if unwittingly so. Part of the reason why Hal is very > > busy with high-end complex cases is because he is doing (at high > > quality and low risk) the cases other surgeons cannot do or refuse > > to do. The same would apply if CMS refused to pay for any > > complications - surgeons and hospitals that figured ways of > > treating high risk cases with low morbidity will flourish and > >
 others will struggle or perish. The patients will be better of > > because they will be left with fewer hospitals offering services at > > higher quality.> >> > Mind you I am not necessarily giving my opinion here just > > explaining that this makes a lot of sense from the perspective of > > the health purchaser, health policy maker, and the patient.> >> > Shoot me....> >> > Ani> >> >> >> >> >> >> Subject: RE: [HSF] Why should Health Purchasers pay for the cost > >> of ourcomplications?> Date: Thu, 4 Oct 2007 07:54:20 -0700> From: > >> ecdouville at orclinic.com> To: OpenHeart-L at lists.hsforum.com> CC: > > >> > Ani, I respectfully disagree. It is one thing to insist on > >> excellent mortality statistics; there was the long standing worry > >> about denial of care to high risk patients. The shifting of risk > >> to out of state hospitals was one documented side effect of this. > >> Once you get in to $100,000 of free care for an unavoidable, > >> albeit
 rare, complication, I believe you then force a dialogue > >> between hospital leaders (business folks) and physicians, which > >> will unavoidably lead to denial of care to higher risk patients, > >> not as much for death, as for complications.> Maybe it is ok, as > >> long as it is someone else?> > ________________________________> > > >> From: openheart-l-bounces at lists.hsforum.com on behalf of Ani > >> Anyanwu> Sent: Wed 10/3/2007 5:34 PM> To: openheart- > >> l at lists.hsforum.com> Subject: RE: [HSF] Why should Health > >> Purchasers pay for the cost of ourcomplications?> > > > I think > >> this issue of Medicare not 'paying' for mediastinitis is being > >> looked at the wrong way.> > Medicare is not refusing to pay for a > >> complication per se - what is happening is that they are > >> penalizing (fining) hospitals for complications that occur. This > >> then provides an incentive for hospitals to reduce their > >> complication rates. Similar
 approaches have been used in the > >> British National Health Service with hospitals fined, or subsidies > >> deducted, if they did not meet specific Department of Health > >> quality targets.> > Hospitals will still get paid for doing the > >> procedure but what it means is hospitals with high complication > >> rates will have higher unreimbursed costs. There is nothing wrong > >> with this situation per se as it exists in most walks of life - > >> people who provide less quality service or inferior goods get > >> penalized financially and people or products which deliver higher > >> quality service cost more to purchase. Health economists will have > >> no problem at all with this. Indeed they would wonder why, for > >> example, a hospital with a 5% mortality rate, one with a 10% > >> infection rate, one that transfuses 70% of patients should all be > >> paid the same for a CABG as one with a 1% mortality, 0.5% > >> infection and 10% transfusion rate.
 The present state of affair > >> where there is uniform reimbursement for all manners of delivery > >> of health care is scandalous. If you went to buy any other > >> commodity you would not expect to pay the same for products of > >> such diverse quality. A car manufacturer could not charge 20,000 > >> USD for a car whose brakes failed every other day and expect to > >> stay in business, yet we would keep getting paid same for a > >> pneumonectomy, and feel we are entitled to be paid the same, even > >> if all our patients died or developed bronchopleural fistula.> > > >> Of course I know I am in the minority but changes like this are > >> inevitable because the present system of US healthcare funding and > >> payment, and that of even welfarist systems like the United > >> Kingdom, and self-pay systems as in many less developed countries, > >> is not sustainable.> > Ani> > > > > From: msfirst at gmail.com> > >> Subject: Re: [HSF] post op mediastinitis
 discussion> Date: Wed, 3 > >> Oct 2007 00:18:27 -0400> To: OpenHeart-L at lists.hsforum.com> CC: > > >> > This is going to be a disaster. By not willing to pay for a > >> problem, > CMS thinks that the problem will go away. We think that > >> these (and > other major non-cardiac wound problems) will all end > >> up at major > medical centers because the primary surgeons will > >> not take them back > (in part since they and their systems will > >> not get paid - and who can > blame them since we do enough free > >> work). Although, from what I > heard, you can still get paid for > >> someone else's problems - which > means all of the major medical > >> centers will get all of these patients > - gee, that sounds like a > >> money saving plan. Who is going to win > out? Of course the MedMal > >> lawyers - that is a no brainer.> On Oct 2, 2007, at 11:47 PM, > >> Douville, Chuck wrote:> > > This discussion is relevant to our > >> cardiac surgery colleagues > >
 around the world, although it is a > >> financial issue only in the USA. > > CMS (center for medicare > >> services), the agency responsible for > > medicare healthcare > >> funding in the US recently announced it would > > no longer pay > >> hospitals for costs due to postoperative > > mediastinitis in > >> cardiac surgery patients effective within the next > > year. > >> Despite perfect glucose control, antibiotic timing etc, my > > own > >> recent morbidly obese re-do AVR pt had his chest open 7 hours > > > >> due to difficult adhesions. S. epi wound infection on day 6 > > > >> required opening his sternum, VAC therapy and IV antibiotics and > >> an > > extra week in the hospital. The only way to avoid the > >> infection in > > this pt that I can think of is to deny the > >> operation to a 60 yr old > > man with critical AS after previous > >> CABG 6 years earlier. I do not > > believe the incidence of this > >> problem can ever be zero. Thoughts?> >
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