Sarah Kliff at Vox highlights the problem of readmissions after kidney stones are busted:
That makes the removal of a kidney stone one of the most basic, most common procedures in the United States – not the type of thing that you’d think would land you in the emergency room a few weeks later.
Except it turns out that, after the extremely routine surgery, one in seven patients actually do make an unexpected trip back to the doctor – and that can cost upwards of $30,000….
how many of these unplanned visits are preventable….Scales, for his part, thinks a good number might be preventable. He points to the fact that people seen at really high volume facilities – places that do lots of kidney stone removals – tend to have 20 percent fewer unplanned follow-up visits than people seen at places that do fewer procedures. That suggests having some kind of expertise in the procedure can lead to better outcomes.
This makes sense. As someone or a team does a task more often,they get better. Their technique gets better, their recognition of that odd little detail which could lead to problems gets better, their supplies are better suited for a particular task and their ability to recognize and recover from an error gets better. It is a simple division of labor and skill.
Right now, the scope of practice for a specialist can be fairly wide. A general surgeon can go to town from neck to ankles. She might have a gallbladder operation on Tuesday, a bile duct repair on Wednesday, a hernia repair on Thursday. An orthopedic surgeon might rebuild on ankle on Monday morning, insert pins into the elbow after lunch, and replace a hip before dinner.
This could change in the future. The broad scope of practice is a necessary skill base, and it can be a necessity in more remote areas, but insurance companies may modify their payment models for better and in the long run, cheaper care in urban areas.
Centers of excellence for elective or non-urgent care may be a major change in the business model of insurance companies. Instead of being willing to pay high benefits to any in-network general surgeon who removes a gallbladder, the insurance company could designate half a dozen surgeons at a couple of facilities to be their “gall bladder docs”. Another set of surgeons at different facilities could be the ACL/PCL/MCL pit crew. Another three or four teams would be the regional hernia groups.
The goal would be to develop very deep experience and a standardized protocal of care. If every person who is having a hip replaced receives the same spare part, the ability to buy in bulk means a much better deal should be received. Training time and learning by doing time would also be reduced as instead of three hundred surgeons in network who need to stay current on a surgery that they’ll only perform a couple of times a year, most surgeons would only need reminder/refresher trainings, while the core team would be involved in daily replacements. The goal is to reduce errors, reduce mistakes and get people better faster and cheaper.
Cheaper is achievable even if the per-operation rate increases as this metholody should result in significantly fewer re-admissions.
There are a couple of big problems with this business practice change. The first is that it would be an insurance company dictating independent business decisions by providers. Integrated payer-providers like Kaiser would have a much easier time making this change than insurance only companies like Wellpoint. The second, major problem, is the teaching hospitals would have a much harder time teaching. It is highly unlikely that an insurer would choose the major regional academic medical center as a center of excellence/preferred slicer and dicer for all major categories of surgery. Medical students would still continue to see all of the unusual and emergency cases that they currently see, but they would probably be classes of common procedures that they would not see on a regular basis.