Sunday’s NY Times Magazine cover story focused on Intermountain Healthcare, a network of hospitals and clinics in Utah and Idaho that is mentioned by many as an example of how care should be provided across the country.
Medical providers and leaders of health care institutions from around the world go to Intermountain to learn about their work creating protocols for care based on evidence gathered over time. Intermountain has compiled protocols for 50 clinical conditions in order to decrease the chances of medical providers relying on intuition without relying as well on evidence.
Intermountain is not seeking to remove intuition from the picture all together but believes that when there is a lack of evidence driving treatment choices, providers will rely on “experience” which often means one or two recent cases or one particularly good or particularly bad case as opposed to what Intermountain’s CEO calls “measured experience,” which takes evidence into account. Intermountain has seen results from its work: reductions in the number of preterm deliveries and in time spent in NICUs, decreases in medication errors and adverse drug events, lower-than-average readmission rates for heart-failure and pneumonia patients, and more.
The federal government and Massachusetts are looking at Comparative Effectiveness Research to help guide treatment decisions in a similar way-doing research to determine which treatments would work best for which patients and in what circumstances. However, as the article points out, change can be slow. As an example, it cites a recent Health Affairs study that reported only half of hospital boards list quality of care as one of their top two priorities. A top concern for hospital boards is financial performance, and, as the article mentions, Intermountain actually lost money as a result of its improvements in performance because of the perverse incentives in the fee-for-service system. The example in the article is what happened when Intermountain standardized lung care for premature babies and, as a result, cut the number of babies on ventilators by 75%. Intermountain subsequently ended up losing $329,000.
As Massachusetts looks to reform the health care payment system, we need to figure out how to encourage care such as that provided at Intermountain without discouraging such innovations because of the way in which care is reimbursed.
-Deborah W. Wachenheim
The key question brought up in this article and in the national debate about health care reform is how to merge quality performance with financial performance. Too often these two measures are at odds. An article in the New Yorker by Atul Gawande, the Cost Conundrum, more specifically looks into the effect of high Medicare costs on quality. Gawande cites research at Dartmouth showing that the more money Medicare spent per person in a state, the lower quality rating that state received. Conversely, the Mayo clinic, mentioned in the NY Times article as well, was cited by Gawande as being among the lowest 15% of Medicare spenders in the country, and it is renowned for its quality medical care. All these studies suggest that financial performance does not align with quality performance.
The rigorous, evidence-based internal “system analysis” that Brent James advocates to improve quality has fallen prey to this reality. His method appears not only to cut unnecessary costs, but also to potentially lose the hospital money, thus threatening to upturn the innovative system. The article blames this perversity on fee-for-service payment. James suggests the answer is a fee-for-health system that would reward hospitals “trying to do the right thing.” An alternative approach currently gaining in popularity that attempts to align quality care with financial gain is “pay-for-performance.” This program is becoming increasingly popular but remains controversial due to relatively moderate improvements on quality and consequences that possibly increase health care disparities. Still, it relies less on change from within, generated by a group of doctors, and more on simple financial incentive; it is based on the ability of physicians’ interest in financial reward to influence their standard of care. Intermountain relies on a hospital committee to “woo” doctors into believing in evidence-based protocol. Although Intermountain appears to be successful in improving its quality, it may not survive its financial losses. Pay-for-performance has major flaws as well, but it may better understand how to control a doctor’s decisions: with money.
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