Publications
APS Bulletin • Volume 18, Number 1, 2008
Pain and the Law
Ben A. Rich, PhD JD, Department Editor
A Call for Integrated, Coordinated Care
Lucian Leape, MD, adjunct professor of health policy at the Harvard School of Public Health, Boston, recently spoke about the greatest challenges facing health care today as part of a series sponsored by the Joint Commission Resources. Leape says that the challenges are numerous and depend on one’s point of view. In short, he says that hospitals focus on survival, patients on access and affordability, providers on morale, and healthcare experts and researchers on quality.
Why are healthcare costs so high? Leape points to the small number of patients with chronic disease, waste (i.e., inefficiency, administrative waste, and poor quality, including the overuse of certain procedures and adverse events that lead to extended hospital stays), and the need of all hospitals to make profits. The following was excerpted from his January 25, 2008, presentation.
How do we handle the two big causes of excess costs? How do we dramatically improve the effectiveness and efficiency in the care for chronic disease, and how do we dramatically reduce waste, inefficiency, overuse, and injuries? Remember, the secret of treatment of a chronic disease is to prevent it from becoming an acute disease—that is, to keep patients from needing high-tech hospitalized care and prevent complications. You do that by providing continuous, coordinated, integrated, multidisciplinary team care that emphasizes prevention and, equally important, early treatment of complications.
Coordinated Care
Not only would providing integrated, coordinated team care vastly improve the life, longevity, and happiness of millions of people, it would save hundreds of billions of dollars. Talk about win-win. How do we make it happen? Simple: pay for integrated, coordinated care, not for individual services. We need to quit paying for providing individual, uncoordinated, episodic, single-specialty care in 10 different places at 10 different times and replace it with a system of coordinated care that is continuous over time and place—in and out of the hospital, the home, and the nursing home—and meets the patient’s need at the right time and in the right environment.
It would be a system where all providers—physicians, specialists, nurses, primary care doctors, therapists, social workers, and technicians—work together as a team to figure out how to best meet all the patient’s needs. You do that by paying a group—a multispecialty group, a clinic, a team, or an HMO—for total care of the individual and not for individual services. That’s right; we have to stop paying fee-for-service. We need to pay an organization to take responsibility for the patient and manage the patient’s care. We need to pay for managed care, a term that has a lot of baggage.
How about we call it coordinated care? The best estimates are that coordinated, integrated, multidisciplinary care for chronic disease reduces hospitalization by up to 90%. That’s certainly true in asthma, and it cuts the total cost of care of these patients by 50%. That change alone would reduce total U.S. healthcare expenditures by 35%. If that isn’t a no-brainer, I don’t know what is.
Waste Elimination
The second approach is also a no-brainer: eliminate waste. Everybody is opposed to waste. The answer for inefficiency is the same as for chronic disease: pay for coordinated, integrated care, not for services. Give people incentives to make the system work. If the money for your salary and mine all comes out of the same pot, as well as [money for] lab tests and treatments, and if the reimbursement is not linked to specific services, there’s a strong incentive for everyone to make the system work efficiently.
In a coordinated-care world, the payer would pay the group a fixed amount per patient, per year. No bills for services are needed. There’s no reimbursement. The plan negotiates capitated payments up front.
[In terms of overuse], if you pay for coordinated team care, you take away the incentives for providing marginal or inefficient services. If your group receives a fixed amount annually for each of your patients with coronary artery disease, don’t you think the number of angioplasties or bypasses would decrease? Of course they would. Talk about an incentive for preventive care—and talk about an incentive for making sure all patients get in, get seen, and get their medications.
The other type of poor quality, preventable harm and failures [in] patient safety, is a little more complicated. The patient safety movement is about changing systems and implementing proven safe practices. There’s a huge effort under way right now to implement known safe practices, but it’s not going very well. It turns out that the Achilles’ heel of implementing safe practices is the dysfunctional relationship among clinicians. It turns out that doctors, nurses, pharmacists, therapists, and technicians often don’t work very well together, so there’s currently a major effort on patient safety in team training. The way to make the system work better is to get the people to work better.
Paying for coordinated care by multidisciplinary teams, which I propose is the secret to more effective and less expensive care of patients with chronic disease, is also the secret to improving safety. Pay for multidisciplinary teams, and they’ll find it in their interest to implement the safe practices.
Where have we seen the greatest successes in patient safety? Where have we seen the zero defects, the total elimination of central-line infections and ventilator-associated pneumonias? The way we’re going to improve safety, reduce medication errors and surgical complications, and work much more efficiently is with multidisciplinary teams. Fee-for-service takes away the incentives to improve process and safety; fee-for-patients, which is really fee-for-coordinated care, provides strong incentives. There’s one caveat: There is a movement afoot among payers to stop paying for hospital-acquired infections. It’s just beginning. Although I agree with the principle of not paying for preventable events, I’m very concerned, as are many of you, about government and payers telling us how to provide care. That will never work. We can push for payment for comprehensive, coordinated care ... by showing that we can provide better care for less, which brings us to the greatest challenge.
Most economists and business professors continue to push for a market solution. The current fad is to get better information to the consumer, make them have some “skin in the game,” provide for choice, and things will get better. But that won’t work; it’s more of the same. It’s the latest version of what they’ve been saying for 25 years—market, market, market. It hasn’t worked, and it won’t work for the simple reason that most people won’t shop for health care when they’re well, and they can’t shop when they’re sick. As Arnold S. Relman, MD, author of A Second Opinion: Rescuing America’s Health Care, puts it, “There are no prudent purchasers in the ICU.” And the market approach has never addressed, doesn’t pretend to address, the problem of the uninsured.
I’m for a single-payer [system]. There’s abundant evidence that it’s the cheapest, fairest, and most efficient. Our single payer, Medicare, has administrative costs of 3% and high patient satisfaction.
Many people, however, think that a singlepayer system is not politically feasible at this time. I’m afraid I have to admit they’re right. The alternative is mandated insurance, either individual or employer. Americans like having their insurance through their job, so probably an employer mandate is the right thing to do, but it will require a lot more regulation to make it work. Remember, what we want is a system that provides coordinated, integrated, multidisciplinary, continuous care, and so we have to require insurance companies to pay for that.
If I was putting in a mandated employer-based insurance system, it would have these characteristics. First, benefits would be standardized. Most important, we need to eliminate the abuses of the commercial insurance system. We need to outlaw exclusions, cancellations, reductions in benefits, and changes in premiums. There has to be community rating. They have to take all comers, give them the same benefits, the same rate, and individuals have to have a free choice of plans. The benefits have to be adequate and standardized.
Second, payers must be required to pay for integrated care, not for individual services. Pay organizations, not individuals, to take responsibility for our population. It’s a capitated system. Pay for care organized in multidisciplinary teams—not reimbursement, but up-front payment. Obviously, to do this, care will have to be subsidized. I favor free care for the poor and a maximum individual outlay for individuals, premiums, and out-of-pocket expenses, totaling no more than 10% of income for the rest of us. Massachusetts and California are currently experimenting with this. If it’s an employer mandate, an important option is to have public insurance such as Medicare for self-employed individuals.
That’s my prescription: pay for coordinated, integrated, multidisciplinary team care, and mandate insurance to pay for that. If you believe in this or agree with it, if you’re a provider or a healthcare organization, you can begin to develop coordinated, integrated, continuous-care models for chronic disease right now. Start on one; diabetes or asthma would be good candidates. Train everyone, doctors included, how to work in multidisciplinary teams, and put pressure on the payers to begin paying for coordinated, integrated care. Speak out for national regulation of insurance; currently it’s a national disgrace. Insist on community rating and push for standard basic benefits. Educate your representative in Congress; none of this can happen without legislation. Support the political candidates who have a plan for universal coverage. The time has come for all healthcare organizations to ask themselves whether they want to lead or to follow. We know how to give better care, much better care. I think that’s the greatest challenge, and I welcome your participation.