I am actually fairly optimistic about long term health care spending in this country declining while quality is also improving for one simple reason. The baseline of stupid, counter-productive, non-coordinated, mistake prone folk practice is so high that we are at least five or six reform iterations away from needing innovative ideas or genius level work to get gains. There are a lot of areas where not being stupid or visibly counter-productive would produce very large improvements in quality and cost. Aligning incentives, rewarding good behavior and punishing bad behaviors on the payer and provider side of the equation will carry us through the next couple rounds of reform. Those rounds won’t be universal improvements, but the weight of change has to be positive.
PPACA is attempting to align incentives correctly on the idea that hospitals should be places where people get better instead of worse. It is an amazing idea. The Centers for Medicare and Medicaid Services (CMS) has been penalizing hospitals that have high readmission rates. CMS has also teamed up with hospitals that serve most of the patients in this country to share best practices on reducing infections and “never” events. Hospitals get paid more if they do good work, and get paid less if they create lots of preventable problems. This is not ground-shaking policy theory here.
Vox has some details on early results of these programs:
The number of patients who had a hospital-acquired condition — anything from an infection of a surgical site or a fall during recovery — fell by 17 percent between 2010 and 2013. That translates to 1.3 million fewer harmful incidents than if the 2010 rate had held constant and 50,000 fewer patients death. The declines span all different types of care. Surgical infections fell by 19 percent. Pressure ulcers (which patients often develop spending days lying in bed) declined by 20 percent…
This decline in hospital-acquired conditions has coincided with a similar drop in hospital readmissions: cases where patients come back to the hospital after something was screwed up the first time. Hospital readmissions began to fall in 2012 after holding constant for years, a change that the Obama administration estimates has saved 15,000 lives
This is a big Biden deal. We are eliminating some of the stupidity, some of the counter-productiveness, some of the human suffering from our healthcare system and saving significant money at the same time. This is a double win on quality and costs. And it is not limited to only Medicare as most of the time best practices are universal best practices among a particular patient pool, so someone on a commercial insurance plan who is hospitalized will now benefit from better central line administration procedures that came from CMS kicking hospitals in the ass.
The day to day politics can be depressing as hell, but the basic scope of potential change is so large and the powerful levels of change are lying about being asked to be used, that I am still reasonably optimistic about the next half a generation that we as a society can cover more people and do so better at far lower costs than business as pre-2009 usual would have projected.