Monday, May 21, 2007
Purchasing Medical Guarantees
I recently purchased a thermos online. Nothing fancy, but something in which to carry tea to class in the mornings. When it arrived, I found that this thermos came with a 5 year guarantee; should any bad fate befall my thermos, I won't be out of a hot beverage container for long. This type of warranty is fairly common to the items we buy; from the 30,000 mile guarantee that comes with a new car to the 1 year warranty on a new computer, consumer goods are almost always insured.
Last week, the New York Times discussed an interesting article on the idea of medicine with a warranty. In a novel healthcare system overhaul, Geisinger Health System of Danville, PA, in the northeastern corner of the state has created a surgical care system in which a flat fee covers the operation and any follow-up treatment that might be needed over the following 90 days. This 'guarantee' is a "distinct departure from the typical medical reimbursement system in this country, under which doctors and hospitals are paid mainly for delivering more care — not necessarily better care."
In the most pragmatic sense, this Geisinger system means that physicians have the greatest economic incentive if they treat patients once and completely, and can move on to other sick individuals, rather than treating the same person repeatedly with (supposedly) suboptimal care. Currently, this program is being used primarily on elective heart bypass surgery, and the improvement in care has been significant, even given the few months the plan has been enacted. There are fewer patients going to the ICU, more patients heading straight home, and a 4% decrease in patients with any complication.
The main way in which this has been accomplished has been through creating a 40 point standard of care checklist, where the various surgeons came together to come up with what they thought were the "40 best practices" in bypass surgery. In my experience, this idea of a simple list or algorithm proscribing treatment is often met with resistance. Whether our egos demand that we physicians could not be replaced by an advanced computer, or perhaps because appropriate health care requires flexibility in tailoring treatment to a patient, the 40 steps for bypass surgery remain open to the discretion of the surgeon.
Reading this reminds me of an article by Atul Gawande, published in the New Yorker, titled The Score. In it, Gawande discusses the Apgar score, a value that describes the condition of an infant at birth. Granted, the Apgar is a retrospective assessment, but it has changed the way care is provided during birthing as doctors aim to maintain higher scores. It gives a comparative framework similar to that of the 40 step bypass which may provide better comparison of techniques and outcomes.
As a medical student, I am only tangentially aware of the hospital's balance of quantity and quality. I constantly hear about the dwindling reimbursement rates for physicians, the enormity of the debt we incur in the educational process, and the long hours and other demands of the hospital that will threaten that balance. I see the figures that Geisinger is presented, and wonder, are these improvements in care transient? Is this a product of the novelty and scrutiny given to this new experiment? Or, like the Apgar score and other such stratifications of care, can it take hold and stimulate further improvement in the field?
It is probably too early to tell. The only insurance that is covering the operation, as of now, is the insurance offered by the Geisinger Health System. Moreover, this has only been used in basically one type of operation, and in one hospital; I can only hope that its results are generalizable. Nonetheless, it is a great step towards improving both the care we receive and how we pay for it, and I can't argue about my favorite statistic from their trial, a decrease in in-hospital mortality from 1.5% to none.