Tuesday, September 09, 2008

Paying Healthcare Providers for Performance.

It is interesting that in today there is an article in the New York Times Science Times about paying healthcare providers for performance, because I happened to have just been working on this same topic. The article clearly, and concisely pointed out the pitfalls of paying for performance. I think there is merit and reason to such a promise, but I advocate a much different system. There is the idea of paying for results, which is different than paying for performance, and is also being tested by Medicare. But as usual, insurance companies and Medicare, just don’t get it. Their solutions fall somewhere in the middle, rather than developing proper methods, they like to use the most basic and limited thinking to reach their goals. In my pay-for-results plan, there is your base pay plus two bonuses for lowering mortality rates and improving treatment rates based on certain criteria. There are no payments for treatment guidelines as in the current system, because it contributes to the risks and abuses pointed out the article, such as avoiding surgery for patients at higher risk or even treating patients who are very high risks, as well as starting antibiotics and other treatments before you are clearly sure of the diagnosis. You earn your bonuses for lowering mortality or treating in the most efficient manner, meaning earliest and easiest intervention. Only if you don’t get a good result while not following the guidelines the government has established, would you be penalized. In this way, you can show that you are able to achieve excellent results without blindly following generalized guidelines. The problem with these guidelines developed by the government is not that they’re bad, because they’re not. Statistically, they are driven as the generalized best practice. However, if people were machines, especially mass-produced well maintained machines like computers, this generalization would work a lot better. The problem is, human bodies don’t all work perfectly alike, and medical science is art as well as science as there is so much still to be learned. Therefore, providers for innovative and maintains strict controls to be on top of the situation can probably do a better job than generalized guidelines. However, if you’re not good at what you do, and you are flouting guidelines without showing a corresponding better practice, you’ll not only get worse results but the system will now be in place to penalize you for it. Patients will need to be set up in the two tiers, with the most sick patients being put in the final tier, and will be judged statistically on a separate basis, so as not to skew your results and lower your bonus. This will help to remove the encouragement, not to take on the sickest and most high risk cases.
Since generalization is built on statistical evidence I am quite sure it saves lives in institutions where the creativity is lacking, or the attention is not quite there, where they are understaffed and overworked, so it is not a good idea to abandon them completely. Rather, they should be used as a measurement tool to compare what treatment is being done at organizations that are doing below acceptable limits. For the best institutions they should be used to figure out what they are doing right and how to ultimately make those generalizations even better.
It is important to create a tier structure that takes into account the kinds of cases, the hospitals are taking on. We don’t want to encourage hospitals to shy away from the toughest cases, or those institutions that currently do, and should handle the toughest cases, to worry about how they may skew their results in a negative manner.
Clearly, we need to hold providers accountable. Just as we want people who repair all our homes or cars. We need to understand that unlike homes, cars and computers, fixing people is not an exact science, and everything we need to know is not known. Having said that however, we have a right to expect that our providers are not only well trained and licensed, but are knowledgeable and prepared to practice using established, statistically beneficial guidelines, unless they have a good and experienced rationale to divert from these guidelines.
We should not allow insurance companies and Medicare to start dictating treatment. When the only way for a provider to get paid is by following the guideline of treatment, even when they strongly have reason to believe they can do better than those guidelines, then they won’t, and medical science will not march forward. Insurance companies and the government are always looking for a way to pay out less, and this is reasonable if they can find ways to more efficiently offer the same or more effective care. However, what’s necessary here is the creation of a more comprehensive and multi-tiered evaluation system and check and balance system, to allow providers to do what they do best, yet help them to avoid some of the pitfalls and errors to which many of them are prone.
We can do better. We must not allow insurance companies, nor government, to choose what is easy and expedient. Simple cost-cutting and financial constraints are not going to fix our health care system, nor halt health care inflation in the future, unless we accept the realities that major change must be affected. At the same time, we must preserve what is best about our system, and that is our well-educated provider system, our top-notch research and development system and our cutting edge development of technology in healthcare and related fields. We can do better and we will do better.

Thursday, September 04, 2008

The Fighting Terrorism Scorecard.

Some Presidents have terror trust upon them, like Bill Clinton in 1993 when, without warning the World Trade Center was attacked. Others are prepared and forewarned with their great understanding of the world around us, like George W. Bush who ran during the 2000 debates as the "anti-terrorism President". After 9/11 George W. Bush said he would have "moved heaven and earth to have stopped those attacks". Since it has long been established that he had warning that Al-Qaeda and Osama bin Laden were planning to use our own airplanes against us in a terror attack, we can presume that rather than figurative, W. Bush was being literal. Apparently he might move heaven and earth, which I am pretty sure he actually cannot do, but he would not order the airlines to lock their cockpit doors; something that has been done since the attacks, and has long been credited with helping Israel's airline, EL AL, avoid hijackings. Because he was warned but failed to act in any way, shape or form, George W. and his administration get a big NEGATIVE on their first brush with terrorism. George W. then invaded Afghanistan, the hideout of Osama bin Laden, after establishing that he and Al-Qaeda were the culprits. That goes down as a big POSITIVE. We then invade Iraq, even though intelligence tells us they are not related to the attacks, do not harbor Al-Qaeda, in fact Saddam Hussein was afraid of Al-Qaeda. That's okay. We don't claim they had anything to do with 9/11. We claim they are dangerous on their own right, preparing weapons of mass destruction and all. When this turns out to be false, and we start to learn that the administration knew these were lies, we suddenly start to claim they were part of 9/11 all along. By 'WE' of course, I mean our Government. Then the bipartisan commission finds, as we knew all along, that Iraq had nothing to do with Al-Qaeda or 9/11. George W. Bush, Dick Cheney, John McCain and Joe Lieberman have apparently not read any of this intelligence or been briefed on any of these reports. Many citizens of our country and people around the word have been getting the message however. That would go down as another big NEGATIVE. Our destroying the Iraqi military and having not a clue how to fill the void allowed Al-Qaeda to, for the first time, get a foothold in Iraq and start killing our troops with roadside bombs and Iran supplied anti-tank and helicopter weaponry. Incidentally, also empowering Iran. Our use of torture and indefinite imprisonment during the conflict has helped to turn Arab sentiment against us that had been won over back by the Gulf War. Our hypocrisy has tainted us not only in the MidEast, but on the entire world stage, emboldening Russia. We'll call that another real big NEGATIVE. Our taking the eye off the ball by going into Iraq leaves the job undone in Afghanistan, allows the Taliban to regroup and lets Osama gets away. NEGATIVE. That's five events with one positive and four negative for, or a 20% positive percentage. If you took math anywhere but President Bush's classes at Yale, you know that is a failing grade. If there is any place where John McCain most agrees with George W. Bush, it is in the fight on terror. Do the math. What is really sad is that because the Republicans talk tough, people actually believe them, even with their abysmal record. These are smart people, some of them anyway. If a stockbroker told them he'd make them a lot of money but had a terrible track record of losing people's money, these people would never listen to them. If they were shopping for a car and the salesman said this is the best car in the world, they would still look up Consumer Reports to objectively verify this. But let a Republican talk tough on terror, and it doesn't matter that they have done absolutely nothing, well, almost nothing, and certainly done almost nothing right. Like I said, DO THE MATH, and if you don't want to vote for Obama, then write in a vote for a house plant, or a sponge, or anything or anyone not McCain/Palin, because this country and its citizens cannot afford 4 more years of fighting terrorism the Republican way. We need to start fighting the real threats and we need to focus on that fight until we beat them! But when you do cast your vote, before you write in that house plant, remember that Bill Clinton, a democrat--shudder---caught the 1993 attackers of the World Trade Center, and when Al-Qaeda attacked us in other countries, Bill Clinton sent in cruise missiles, and when Saddam Hussein would break the no-fly zone, Clinton would bomb his bases and other military targets. By that count, Bill gets a passing grade. You can vote Obama, or vote for a sponge (Spongebob for President, anyone?), but I think we'll all probably be better off with Obama.

Wednesday, September 03, 2008

Country First

Country First. That's the sign that the Republicans wave around at their convention. I guess they are trying a change of pace, since they tried putting their country last and the richest people first from 2000-2006. They still put their country last from 2006-2008 but it was less comprehensively because they lost the congress, because the country woke up and realized they were being put last. Just about their entire convention has been about veterans. Veterans are heroes and patriots, but that does not mean they are qualified to be President. If you only had to be a brave war hero, then John Kerry would have been our President the last 4 years, and America might have already been on the road back to the greatness it deserves. We can't change the past, but we can fix the future. The Republicans had their chance...and they messed things up. True, we don't need Obama to get us out of Iraq because despite what the Republicans want; Bush wanting the war to continue and McCain saying we will stay there 100 years, the Iraqis are throwing us out! Still, we need a change to right so many other things. Vote Obama. Or go ahead and write in your vote for a sponge, a Buick, a house plant, what-have-you, just not John McCain or any other Republicans.
By the way, did you notice those young Republicans cheering Rudy Giuliani saying John McCain would keep the fight against terrorism on the offensive? Why are they at the convention? Why haven't they enlisted to fight the good fight in Iraq (or even better---the real fight in Afghanistan)? The old Republicans love to cry for war because they aint going, and they aint sending their kids either, make no mistake. Seem a bit hypocritical? Alright, it's true, not just a bit. Of course, not all Republicans are hypocrites. John McCain's kid is in Iraq (as will soon be Joe Biden's), and Palin has family going as well, but sadly, that is pathetic, not patriotic. The only terrorists they will get to shoot at in Iraq were ushered in by George W. Bush, as has been pointed out in this blog before. If Republicans are so easily fooled, and fail to learn when the truth is pointed out to them; that Iraq had nothing to do with 911, and a bipartisan commission pointed that out, and that the Bush Administration lied, and covered up these issues, how can you trust such easily fooled people to run your country? The answer of course, is you can't, and when you try, you get the last 8 years. And Bush was the guy doing the fooling! He's the clever one! The rest are just still believing the lies he sowed! At this point it should just be NUFF SAID. Time will tell.

Monday, September 01, 2008

More on Health Care Reform. Changes to come.

I just want you to know that I have happily worked for insurance companies selling both life and health insurance as well as managing entire units and regions for those companies. Nevertheless, I must call this section, "how the evil insurance companies screwed up everything".
You see, in the 70s and 80s, when insurance companies are able to make ordinals of money on safe interest-bearing investments, they took their eye off the ball and simply reimburse whatever charges doctors and hospitals submitted. This allowed for out of control costs growth and waste. There was no fiscal discipline for decades in healthcare. This is by far not the only cause of the situation, but because the insurance companies acted as insulation between the public and providers, there was never the need to deal with the spiraling costs. Of course, due to the complexity of healthcare, it’s never going to be cheap, and there is no developed nation where health care is quality where it is cheap, although in many places it's less costly and more efficient than it is in the United States.
Now, I don't blame the insurance companies for everything or necessarily even the majority of the current problems. I also wouldn't blame them almost at all if they made a reasonable rational attempt to fix the problems that they did create. But they did not they, like the government, tried Band-Aid fixes that not only do not address the problems that are unfair in their attempts at what meager solutions they offer.
Their cost containment solutions are always aimed at the end providers, ignoring what those providers cost of doing business really is. Now, I have stated myself but I believe we spend enough on healthcare already, but I know that to fix the system to make it operate on these budgets requires major policy retooling. To go to the last end of the providers and say you've got to charge less, we are not paying you any more next year than we did this year, we are only paying for this many days of hospitalization and we won't take into account that people aren't machines and we can't always know exactly what's going on inside them and what the outcome is going to be, are all punitive measures with no rational basis for expecting them to work , or work efficiently. Neither government nor insurance companies get it. There is no simple fix here. Insurance companies place in this business is going to need to change drastically. Insurance companies and HMOs aren't doing a good job, aren't doing the right job and aren't set up correctly for what our healthcare system needs. On a much more superficial basis I am going to begin to lay out here what I do much more comprehensively in my book; and that is how we are going to need to remake the interplay of insurance companies, government funding and healthcare providers into something that works now and will continue to work into the very far foreseeable future.