Disease (dĭ-zēz’) n.
- A pathological condition of a part, organ, or system of an organism resulting from various causes, and characterized by an identifiable group of signs or symptoms.
- A condition or tendency, as of society, regarded as abnormal and harmful.
The current state of the US healthcare system is not only abnormal but is harmful. The litany of evidence to support this has been rehashed ad nauseaum in multiple forums by far more competent and analytic minds. As I have tried to grok the fundamental challenges in the industry, I have been totally amazed at the perverse incentives, the twisted regulatory environment, and the befuddled attempts at reform that have led to our current healthcare state.
Amidst this intensive review, I could not help but notice the dramatic irony of several interesting word plays common to the banal language of everyday healthcare. Take, for example, the very word “Healthcare” as a description of what thousand of hard working, well intentioned, and occasionally idealistic health workers attempt to provide to their patients. The irony is the the current environment does not reward “Healthcare”, but rather is built on a system of “Diseasecare“.
The very practice of medicine has traditionally been all about disease – the pathology, the dysfunction, the damage, the injury, and the toxicity. Reimbursement strategies grew up around this philosophy and model, and quickly oriented to a payment structure that rewarded for treatment and procedures. Physicians who did some type of intervention were paid, whereas the physicians who did some type of prevention measure (that oftentimes could prevent the intervention in the first place!) were not. While certain reformers and managed care organizations attempted to control runaway costs with various incentives to undertreat, simultaneously, physicians were left with the incentive to treat, and to treat more to get paid more – thus ensuring the propagation of Diseasecare within the US healthcare system.
A paraphrased excerpt from Redefining Healthcare discusses this concept:
Ironically, providers incentives to undertreat due to health plan reimbursement rules and structures coexist with incentives to overtreat, compounding the problems for patient value. Incentives to overtreat have four sources. First, physicians and hospitals get paid to treat, not for keeping patients healthy. Second, when reimbursements are squeezed, the incentive to treat more becomes stronger. Third, the phenomenon of “supply driven demand” (more specialist = more specialty care provided). Fourth, physicians will provide as much care as possible out of several obligations to “do something”, increase patient satisfaction, and reduce the risk of malpractice claims (overtest, overtreat, overrefer).The net result of the simultaneous incentive to overtreat and undertreat is poor quality and poor value.
The Diseasecare reimbursement model creates all kinds of financial, clinical, and ethical conflict. Consider the following example, again from Redefining Healthcare:
For example, Intermountain Health Care embarked on a project in 1995 to lower the rates of community-acquired pneumonia in Sanpete County, Utah. Treatment process guidelines developed as part of the project focused on the initial triage criteria for hospitalization, the choice of initial antibiotics, the work flow to get antibiotics started quickly, and a conversation protocol to shift inpatients to medications that could be delivered in an outpatient setting. The implementation of the guidelines resulted in a reduction in the rate of complications and a lowering of the patient mortality rate.
While the project lowered the total cost for the episode of care, however, Intermountain’s leadership quickly realized that the quality improvements were cutting into the IHC bottom line. While IHC’s costs of care had dropped 12.3%, the revenues had dropped by 17.5% because as the complication rate fell, the Medicare reimbursement rates shifted from complex DRG’s with positive margins to simpler DRG’s with negative margins.
Diseasecare puts the physician in conflict with the patient, the patient in conflict with the hospital, and the insurer in conflict with everyone. It does not result in higher quality, encourage innovation, nor increase value. Correctly identifying the perverse incentives of Diseasecare as an identifiable group of symptoms to cure will be the work of the next generation of Healthcare workers truly focused on a novel paradigm of “health” care. In fact, the promise of the “Health 2.0” revolution is to vaccinate against this type of disease oriented thinking through consumer empowerment, information collaboration, value added healthcare advisory services, and focus on value-based competition over the cycle of care.
Flu shot, anyone?