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Senior pediatrician, Ezras Choilim Health Center, Inc. and retired physician executive.
The cure for the ills of healthcare lies within our grasp. It’s called “managed care,” which simply means care that is efficient and effective.
Editor’s Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Jeffrey Gene Kaplan, MD, MS, a senior pediatrician and retired physician executive. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.
Jeffrey Gene Kaplan, MD, MSIn terms of the ‘bang for the buck’-what one gets for the amount spent (read: invested), the United States pales in comparison to other countries. And, the disparities are particularly poignant when it comes to the egalitarian treatment of patients from all strata (in other words, universal accessibility), and best achievable heath status (i.e., benefit).
More from Dr. Kaplan: Who is ruining the healthcare system?
This blog contends that cure for the ills of healthcare lies within our grasp. It’s called “managed care,” which simply means care that is efficient and effective. But, that cure requires that one is able to use data analytics, which, in turn, relies on being able to answer the following three questions: In the health plan or system 1) What works? 2) What does not? 3) And, are patients getting what they need, i.e., the right care at the right time and place?
1) Foster teamwork, such as one can find in a group practice, accountable care or preferred provider organization in a medical home environment. Ideally operating around a hospital or some such community resource, the team’s techniques and management strategies include peer review, aligned performance incentives (i.e., do things well and be recognized), communication and information sharing and a computer-assisted case management and accountability system that feeds data analytics-the lynch pin of healthcare management1.
2) Supply effective public health and preventive medicine services; make them available to entire populations based upon obvious and subtle needs, but within budgetary constraints.
3) Levy a modicum of insurance or taxation cost sharing to raise awareness of the costs of care (to have ‘skin in the game,’ so to speak) when paying for some appropriate health services, applying these funds broadly across populations and longitudinally over time. (See #10, below)
4) Share responsibility and accountability among patients, practitioners and/or systems of care, particularly for: adverse life-style choices for which there has not been substantive intervention; medical-surgical non-adherence; failure to cost-share and, thereby prevent inappropriate or unnecessary care; and failure to take into account non-prescriptive, readily accessible specialty society or peer-reviewed guidelines of care.
More from Dr. Kaplan: Why managed care is the best way to reform healthcare
a) Share decision making, which can provide numerous benefits for patients, practitioners, and the healthcare system itself. Among these are: informed patients/consumers, greater adherence to orders and care process, better health outcomes, reduced variation in care and costs, and improved patient satisfaction2.
5) Enhance communication and coordination between medical and community services. Improve medical education by strengthening the bio-psycho-social content of curriculum. Also, increase the supply of primary care practitioners.
6) Align the incentives to ensure that everyone's on the same page with the objectives of providing efficient, effective, and accessible care. Speaking as a practitioner, I should be able to earn a premium based on how much I can improve a patient’s health. Should that fail, at least recognize my efforts and its quality.
a) The obverse is that there can be no incentives for over-utilizing-for instance, giving unnecessary antibiotics or shotgun, “blind alley” testing. Also, there can be no incentives for under-utilizing, such as from over-referral (i.e., dumping patients), delaying or cutting short physical therapy, patient education, mental healthcare, etc.).
b) Incentives should include, but not be limited to providing payment when established goals and objectives are met.
c) In other words, wherever possible, we should be aligning payment and quality in the interest of motivating improvement.
7) Transparency and public reporting, especially as it pertains to systems improvement such as variance analysis, corrective action planning (CAP), timely feedback and monitoring.
8) Encouraging real, salutary quality improvement. “It would be misleading to say that mere transparency had motivated surgeons, for instance, to make improvements that they would not have done otherwise. I believe that most if not all concerned professionals are interested in continuous quality improvement. Indeed, I have found that most practitioners will pick up on real or even putative deficiencies, learn from the introspection, and develop new techniques, improving what has to be improved, incrementally if necessary.” [Paraphrased]
9) Communicate results and close the feedback loop to practitioners about outcomes in real-time (i.e., at the point of contact with the patient and with believable data). For that, one needs acuity adjusted data, allowing "apples" to be compared to 'apples," rather than when "apples” were being compared to "oranges."
10)Finally, to manage care, one needs a longitudinal perspective – that is, all care over time, regardless of setting, the definition of a reliable type of observation -- an 'episode of care.'
2. See Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. "Shared Decision Making to Improve Care and Reduce Costs" N Engl J Med Jan. 3, 2013; 368:6-8.