But take a look anyway, if you have an interest in process improvement in hospitals. This is a collection of my best posts on this topic.

Monday, November 24, 2008

The ad I would buy

I was joking with a friend the other day that the Boston Globe Spotlight team (their investigative group) has managed to become a profit center for the newspaper, rather than a cost center. How so? Well, the main subject of two recent articles, Partners HealthCare, has been buying a series of editorial page ads in anticipation of the articles and today published a full page ad in response to them.

Relying on the placement of MGH and Brigham and Women's Hospital in the top ten of U.S News & World Report the ad notes that:

[T]here are real differences in quality between hospitals. Year after year Partners HealthCare hospitals rise to the top of this list because of investments in teaching, research, safety, and technology. Our patients continue to choose us time and again, especially for complex treatment. And the ultimate measure of quality is that physicians and other hospitals in the area frequently send their most challenging cases to our teaching hospitals.

We realize that there are costs associated with excellence. teaching hospitals, including MGH and Brigham and Women's, care for the sickest patients, the most complex diseases. We subsidize a broad range of service, some of which lose money, such as psychiatry and community health centers.

I can't afford these kind of ads, so I'll offer some thoughts here.

Can we please start by agreeing that these are two very impressive hospitals, staffed by superb physicians, nurses, and others, and deserving of substantial praise in many, many respects? We can also agree that they are destinations for very sick patients and that they subsidize many important services that receive insufficient reimbursement from private and public payers.

But, can we also agree that the differential in rates received by these two hospitals and the doctors working in them is not related to documented, quantifiable differences in quality between them and, say, BIDMC and Tufts Medical Center, two academic medical centers that are also acknowledged for their excellence and that are also destinations for very sick patients and that also subsidize many important services that receive insufficient reimbursement from private and public payers?

Can we also agree that, likewise, there is no documented, quantifiable difference in quality between Partners' community hospitals (like North Shore Hospital) and other community hospitals (like Beverly Hospital)? And yet, the rates received by those community hospitals and the doctors working therein are generally higher than the non-Partners community hospitals.

And finally, can we agree that the higher rates received by community primary care doctors and specialists in the Partners system are not related to documented, quantifiable differences in quality between them and non-Partners community doctors?

When you cut through it all, that is what the Globe stories were about. Everybody knows that Partners is able to achieve higher rates from private insurers because it has more market power than others in the Boston area. The Globe simply documented the figures that we have all heard about for years. Who can quarrel with this business model, envisioned at the creation of Partners years ago and executed superbly?

The issue for today, it seems to me, is whether in a region characterized essentially by nonprofit hospitals and nonprofit insurance companies, the government agencies that supervise those charitable institutions should care that this imbalance exists. This is more a question to be asked of the insurers than of the providers.

Now, here's the heart of the question. Is this a zero sum game? Is there some fixed pot of insurance premiums to be allocated, so that if rates for other hospitals were to rise, those for Partners hospitals would have to fall?

Regular readers of this blog know that my answer to this will be, "Wrong question." The correct question is how much money could be saved in the health care delivery system if we were all to invest in quality and safety and other process improvements. The answer is, "A lot." The first step, though, is to move towards basing rates on the quality of care delivered -- to give the proper incentives to make progress in this direction. Sorry, not quality as portrayed by a magazine, but as documented from actual clinical records, the kinds of records maintained by all of us, in real time, every day of the year.

Let's measure improvement in avoiding central line infections, ventilator associated pneumonia, "codes" on medical floors, and other preventable harm. I'm not saying that reimbursement rates should be mainly based on a comparison of hospital A's to hospital B's infection rate. Perhaps it would actually be more effective to emphasize the rate of safety and quality improvement within each hospital as an entity. And, please, let's get away from pay-for-performance reimbursement systems that use process measurements of the type collected (and two years late) by the government. (By the way, some of these have uncertain validity or perhaps harmful clinical results, e.g., 4-6 hour timing of the first dose of antibiotic for patients with pneumonia in the face of an uncertain diagnosis.)

In summary, I don't think Partners needs to defend itself for executing a thoughtful business plan. I think it is the public officials who supervise the nonprofits in the health care sector who should feel some time pressure. They need to figure out, and quickly, how to fix the disconnect between reimbursement rates and the degree to which hospitals achieve quality and safety improvements. It is the pursuit of those improvements that offers us the first and best hope to control the rise in health care spending in Massachusetts.

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