Not being stupid is smart

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.

 

26 replies
  1. 1
    MomSense says:

    The sad thing about the depressing politics is that all the misinformation and fear mongering have scared too many people from signing up for health insurance. I deal with this all the time at work. They tell me that they figured it would be too expensive, that they would have to submit to testing, even that they would have to “get chipped”. I finally convinced one woman who is relying on a cobbled together Free Care program at a local hospital to treat a neurological condition. She was crying when she came into the office and told me that she had called a healthcare navigator and will have a cost-sharing silver for $35 a month. She couldn’t figure out why she had heard such terrible things. When I asked her which news shows she watches, she said FOX. I sort of joked and recommended she turn that stuff off because it’s bad for her health.

    The politicians and pundits who scare people about ObamaCare have health insurance themselves. Do they know or care that they are causing misery? It is a distressing situation and probably the only thing that will counter it is just time. In five years people will just sign up, change plans, report life changes, add a kid to their plan as if it has always been this way.

  2. 2
    GHayduke (formerly lojasmo) says:

    Good news. Thanks, Richard.

    Nice story. Strong work, Momsense!

  3. 3
    BGK says:

    Plural of anecdote not being data and all, but:

    I had occasion to be overnight in the local public hospital last month. What struck me right off was how much more visible and rigorous the hygiene and infection-prevention procedures were. Simple things like hand-washing or -sanitizing and glove-changing where the patient can see them happen. As those small but critical things are given short-shrift even in the “best” hospitals, it was confidence-inspiring.

  4. 4
    cmorenc says:

    @Richard Mayhew:

    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.

    Or, reduced to a bumper sticker:

    “Not being stupid is good enough”

  5. 5
    OzarkHillbilly says:

    @MomSense:

    Do they know or care that they are causing misery?

    No.

  6. 6
    Yatsuno says:

    We are eliminate some of the stupidity

    Not to mention the grammar.

    This is reminding me of the grumbling that surgeons supposedly did when administrators imposed checklists on surgeries. They bitched and whined and complained. Then a funny thing happened: mistakes went down. Like WAY down. And it was one simple change that did it. Something tells me a lot of our health care issues come down to simple changes like that.

  7. 7
    Suzanne says:

    @Yatsuno: YES. Doing what I do, I see doctors and nurses say, “This is how I work. It is the only way possible to do this. Any change to how I have been doing this for the last twenty years is completely stupid and unnecessary. No one could possibly do this differently.” Then something happens, they do it differently, and they have a good outcome.

    I had this happen with a radiologist, when I told him that he would have to scrub up outside his procedure room. He swore that one could only scrub AFTER walking through the door. (This is very gross.)

    Health departments and licensing agencies know this shit. It will just take years to get people to change their habits.

  8. 8
    Richard Mayhew says:

    @Yatsuno: Grammar is overrated :)

  9. 9
    Richard Mayhew says:

    @Suzanne: Before I was in health insurance, I worked as a program evaluator/statistical quality control guy for a couple of years. One of the biggest challenges I always had when I worked with a new group of people was getting the mindset that everyone was a special snowflake out in the open and then out of the room. Docs believe they are special snowflakes and the cultural/institutional support for that idea is very strong and prevelant. They aren’t.

  10. 10
    Tommy says:

    @MomSense: Oh I hear you! I work for myself and I saved $87/month and got a better plan (with no subsidies BTW). In fact, and I might in the vast minority here, but I am looking to UPGRADE my plan in the next couple weeks (been a very good year for my business). This isn’t even factoring in I am now 45, and getting to that age where are as a male I need to start getting some preventive testing done. That is freaking FREE.

  11. 11
    Violet says:

    @Tommy:

    I am now 45, and getting to that age where are as a male I need to start getting some preventive testing done. That is freaking FREE.

    Technically it’s free, but be cautious about your expectations. Current example: go for annual physical, doctor says we need to do a treadmill stress test EKG. That’s not covered. Regular EKG is, the doctor-prescribed treadmill EKG is not. Preventative colonoscopy is covered–if they find anything while they’re there and snip out a polyp for testing, that is not covered. Mammogram for women is covered, but if they can’t read the films and you have to retest, then that is not covered (this happened to a friend of mine and she had to pay for the retesting, which was not due to finding something suspicious but due to the films not being good.) Etc.

    Just be sure you know exactly what is covered and what is not. It’s very confusing.

  12. 12
    SenyorDave says:

    @OzarkHillbilly: Do they know or care that they are causing misery?

    Yes and no. Fixed

  13. 13
    Tommy says:

    @Richard Mayhew: Of course, everybody thinks they are “special” (myself included). That is why when looking at numbers you don’t take a sample of 5. You take a sample of 500, 5,000, or 50,000. Then those “snowflakes” find other similar “snowflakes” and the data becomes reliable.

    I once ran the research department at an ad agency. I was more the project manager, not the day-to-day stats guy (although I have a limited background). We’d hire the focus group moderator, somebody to crunch the numbers in SPSS, and somebody else to put together the methodology and survey design.

    It never, I mean never ceased to amaze me how little understanding most people had, I am talking senior level executives at Fortune 200 firms, of how numbers much less statistics work. Although I would say about 25% of my clients, and they were never this blunt in saying it (one was actually), but their meaning was clear, “can you make these numbers make me look good … this is coming out of my budget you know.”

  14. 14
    Violet says:

    @Richard Mayhew:

    Docs believe they are special snowflakes and the cultural/institutional support for that idea is very strong and prevelant. They aren’t.

    Quoted for truth.

  15. 15
    Tommy says:

    @Violet: Thanks. I know not everything is covered and will admit I have NO clue what is an isn’t. But I am guy that asks a lot of questions of my plumber. I will ask a ton of the doctor when I start to get these tests done. I mean a ton of questions to where the guy/gal will “hate” me.

  16. 16
    Riley's Enabler says:

    Well, I waded through the halls of the healthcare.gov site yesterday. I’d done my “window shopping” last week, found the plan I wanted (old plan was discontinued), was ready to go. 2 1/2 hours later, two frustrating phone calls and even a few tears…I *think* – think being the operative word – I might be signed up.

    This is contingent upon the fact that I had to upload copies of my birth certificate and my SS card to the site. The nice lady on the phone was baffled, I was baffled (and very frustrated). I’ve paid taxes for 30 years. I’ve had the same SSN since I was born. In the US. In the same state in which I currently live, and have for 25 years. All this under my “verified” name and identity.

    Of course, I didn’t get to this level until I’d spent an hour patiently explaining to the other nice lady that no, I do not qualify for Medicare, and no, I don’t know why the site insists that I do, and therefore cannot buy insurance though the site. Sigh.

    My costs went up about $30 a month (no, I don’t qualify for subsidies, nor medicare), but I think – THINK – I will have a new policy come Jan 1.

    I think.

    I sure hope they tinker on the site a bit. It’s random OOPSIES are befuddling. And yes, I filled out the forms correctly (even the nice lady who was looking through it said I did).

  17. 17
    Roger Moore says:

    @cmorenc:

    “Not being stupid is good enough”

    I would say that his bigger point is that there’s enough low hanging fruit to feed the whole country for a few years.

  18. 18
    Mnemosyne says:

    @Riley’s Enabler:

    You may want to call the IRS and/or check your credit report. I’ve heard that things like that can happen if your SSN was stolen and you didn’t know about it.

  19. 19
    WereBear says:

    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.

    Not only is this brilliantly delineated, I would say it goes for everything in the country right now, not just the medical delivery system.

  20. 20
    Mike in NC says:

    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.

    This just means Republicans need to work a bit harder to repeal PPACA.

  21. 21
    Mnemosyne says:

    I’m gearing up for a fight with my insurance company because I’ve gotten the bills from my colonoscopy and I’m pretty sure they decided to play that game where the hospital and doctor are in-network, but somehow the laboratory is magically out-of-network and I have to pay for most of it. I haven’t gotten my explanation of benefits yet, though, so it’s possible that someone at the lab jumped the gun and sent the bill before it got all the way through the system at Cigna.

    Someone’s getting yelled at, because I want Cigna to explain why they authorized everything about the procedure except the lab. Who was supposed to get that authorization? Why didn’t they tell me ahead of time that an authorization was missing? To me, it seems like their fuckup and therefore their problem to fix, and I’m more than willing to raise a stink with my employer about it.

    (The Giant Evil Corporation I work for is “self-insured,” which means that Cigna administers the plan but the GEC pays the bills, not Cigna. It gives me a little more leverage in these arguments.)

  22. 22
    Violet says:

    @Tommy: The doctor will not know, most likely. You need to check with the billing office and your insurance company and even then be prepared that NO ONE can tell you if a test is covered and how much it will cost. I could give you a long list of frustrations with not being able to find out how much something will cost. One time I spent three straight days attempting to find out. In the end it simply was not possible. I made the women in the billing offices of the the doctor’s office and radiology center cry.

    You may have seen my recent posts about why the exact same procedure at the exact same imaging center prescribed by the exact same doctor on the exact same insurance was billed at two different rates. Turns out the real charges were hidden and I had to call three different companies even to discover that, let alone find out what the charges were.

    Our health system is truly a mess. From the consumer point of view it’s utterly opaque and baffling.

  23. 23
    low-tech cyclist says:

    A Democratic Party with a clue would be trumpeting this from the rooftops, that the ACA has already saved 50,000 lives. (And that was even before the Medicaid expansion and the opening of the Exchanges.)

    The ACA was really pretty fucking amazing – here this one little part of the bill has already had that big an impact.

    A political party with any sense would have figured out by June of this year that they wanted to own the ACA, not run away from it.

  24. 24
    mclaren says:

    This post gives Balloon-Juice readers an up close and personal look at Richard Mayhew’s ignorance as well as his dishonesty. Thus it’s an excellent post, since it’s a 2-for-1 shot. We get proof of Mayhew’s penchant for lying about health care cost, and we also get a sense of what’s behind those ongoing lies — total self-delusion.

    Spending at Massachusetts’ biggest health insurer and health care provider helped drive overall health care spending well above inflation last year, as the state’s efforts to control rising costs met mixed success, according to a report to be released Tuesday.

    Spending at Blue Cross Blue Shield of Massachusetts jumped 3.65 percent, and as much as 4 percent for some Partners HealthCare patients last year, compared with an inflation rate of 1.4 percent in the Boston metropolitan area. Overall health care spending grew 2.3 percent, according to the report from the Center for Health Information and Analysis, a state agency.

    “The biggest insurer, the biggest provider — that’s where there’s continued cost growth,” said Aron Boros, executive director of the Center for Health Information and Analysis. “You could almost say as goes Partners and Blue Cross Blue Shield, so goes Massachusetts.”

    Source: “Spending on Health Care Rises in Mass.,” The Boston Globe 1 September 2014.

    Despite the bogus claim of “mixed success,” the Boston Globe headline nails it — health care spending is up substantially higher than the rate of inflation in Massachusetts again this year.

    Remember: Massaschusetts is the pilot program for Obamacare. That state implemented the ACA provisions first, before the ACA was even passed.

    So if you want to see the future of health care spending in America under the ACA, look to Massaschusetts.

    And what do we see?

    Costs in Massaschusetts are soaring. The Masschusetts health care cost curve is on a 16-year doubling time. That means that the real cost of health care after accounting for inflation will double every 16 years at this rate.

    Do the math. 16 years from now, premiums will cost double in real dollars what they do today in Massachusetts. That means that premiums will double in real terms within 16 years. Employer health care insurance outlays will double in real terams within 16 years.

    Do you think that’s sustainable?

    Obviously Richard Mayhew does. Richard Mayhew keeps telling us everything’s hunky-dory in America’s health care system, the ACA is great and just keeps getting better.

    The real numbers say health care costs are doubling in real dollars every 16 years.

    Right now, a blue-collar family of modest means can count on burning through 25% of their after-tax income on health insurance. See this post for details.

    So Richard Mayhew is telling us everything will be fine ‘n dandy in anther 16 years, when the average blue-collar working family’s health insurance costs double in real dollars and they have to burn through 50% of their after-tax income to pay for health insurance.

    Seriously.

    Does anyone think that spending 50% of your after-tax income on fucking health insurance is something the economy of this country can withstand?

    From this post, we get a panoramic view of Mayhew’s disconnection from the real world full of real people with average incomes. Super-wealthy CEOs like Mayhew don’t give a shit, everything’s great for them and getting better. For the rest of us, the ACA is a band aid on a resected aorta.

  25. 25
    mclaren says:

    @Mnemosyne:

    But…but…but… Richard Mayhew keeps telling us how health care costs are declining, Mnemosyne.

    Haven’t you been listening?

    Alternatively, you might want to just bite the bullet and point out that Mayhew is a lying shill for corrupt medical devicemakers, corrupt hospitals, bribe-taking doctoring, bribe-paying big pharma, and labs and imaging clinics run by those selfsame corrupt bribe-taking doctors and hospitals.

    How long will it take, people?

    When will someone else step up and point to Richard Mayhew and state the plain obvious fact: “This guy is lying his ass off about health care costs because he’s making beaucoup bucks off a corrupt system”?

  26. 26
    Porlock Junior says:

    @Yatsuno:

    We are eliminate some of the stupidity

    Not to mention the grammar.

    All your stupidity are belong to us. (2016 Republican campaign slogan)

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