Should hospital patients get treatment to avoid blood clots 24 hours before surgery? Then 24 hours afterward?
Should they get vaccinated for pneumonia? For influenza?
Should hospital patients with pneumonia have a blood culture before taking antibiotics?
Should patients receive clear discharge information, to understand their medications and therapies? Should hospital rooms be quiet and clean?
The answers: yes. Of course. Medical experts have said so. Of course hospitals should do these safety precautions.
Yet “shoulds” are not necessarily routine – not for people, not for organizations. We can recite the usual suspect-culprits: Inertia. Too little time. Overriding crises. Low priority. Poorly trained staff. Overworked staff. Finally, no genuine accountability for overlooking the “shoulds.” Staff might apologize, profusely. Hospitals might promise to do better. But neither staff nor hospitals will suffer consequences — assuming that anybody monitors these measures.
So the Affordable Care Act – aka Obamacare – deserves praise for treading into that murky quicksand of “quality.” Everybody wants “quality.” Everybody strives for it. Everybody claims to have achieved it.
But Obamacare does more than plead, encourage, prod: it waves the stick of money. Not a lot of money. And maybe not enough money to prod changes. But this legislation has linked government payment to performance; the move deserves more than a below-the-fold mention in the media.
Briefly, Medicare compiled a list of 12 “clinical standards of care,” including the above measures. Medicare then included questions from patient-surveys on their experiences. Not every hospital patient will receive all the care they should; indeed, there may be mitigating circumstances (like an emergency) to explain the deficiency. Not every patient will praise the quiet of a hospital room. The beeping machines and nightly checks go along with hospitalization. Medicare compiled percentages to monitor performance. What percentage of patients were vaccinated for pneumonia? What percentage of patients reported that their hospital rooms were clean and quiet?
Then Medicare withheld 1% of hospital payments, and re-allocated that 1% to hospitals depending on their performance. The total pot came to almost $964 million dollars. This is a zero sum game: 1557 hospitals gained; 1427 lost money. To see how hospitals in your state fared, check <http://www.kaiserhealthnews.org/Stories/2012/December/21/value-based-purchasing-chart.aspx>. (The formula does not alter payments for teaching, capital expenditures, or low-income patients.)
The money was not a significant budget item for hospitals. Most of the losing hospitals lost less than .25% of their expected payment.
This move to tie payment-to-performance follows an October initiative, when Medicare tied payments to hospital re-admissions. In hospitals where patients returned within a month, Medicare withheld some money. The rationale: hospitals were discharging patients too quickly and/or not giving sufficient discharge information or follow-up. Admittedly, patient care is not an exact science, and many patients, particularly elderly patients with multiple diagnoses, may have gotten sicker after discharge. But some patients might have benefited from longer stays and/or better planning.
Medicare is considering more performance measures, like death rates from pneumonia and emergency room wait-times. Private insurers may follow Medicare’s lead.
The measures don’t point to “bad” or “good” hospitals. Some of the most-respected hospitals lost money, like the Massachusetts General Hospital. The hospital that fared the best was the 10-bed for-profit Treasure Valley Hospital in Boise. The complexity of patients surely influences the outcomes. Indeed, “quality” is easy to desire, harder to define. But to improve quality, you must translate it into concrete measures. Every statistical measure will draw criticism; every formula that redistributes money will anger the losers. But money – more than exhortations and encouragement – can change behavior.
Uncle Sam has long been a major purchaser of hospital services. Now Uncle Sam is a prudent investor, demanding value for money – a principle fundamental to conservatives and liberals alike.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email firstname.lastname@example.org.
From The Progressive Populist, March 1, 2013
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