I suppose it’s only natural that we are distracted. The media will always focus on the dramatic aspect of the story. Political strategists spend days in fluorescently lit rooms devising new ways to keep us misdirected (think death panels). Our academic research agenda continues to prioritize technological advances over efficient healthcare delivery. And our fragmented payment systems all but guarantee that care providers will waste their time on the wrong financial analyses. “Perverse” is an oft-used term to describe our reimbursement system; it aptly describes my experience with “performance” data. How is it that I am regularly subjected to financial reports detailing every bit of billing and coding minutiae, but it takes an act of Congress for me to find simple clinical outcomes data, let alone costs of care? Value is the forgotten stepchild of healthcare reform rhetoric.
Thus, the publicizing of overuse in NICUs is a microcosm of the quagmire that we find ourselves in today. Healthcare spending is a tsunami projected to devastate the shores of our national economy in as little as five years. In the shadow of this rapidly receding financial wave, competing interest groups stand barefoot on the beach debating whether the clinical waste surrounding us is really pollution (one person’s waste is another’s income, as the saying goes). It’s as if we’re all frozen by the spectacle, unable to move toward higher-level value solutions.
All sides will agree, however, that we are quickly running out of time. Continued inaction will condemn us to a crash financial evacuation of cholera-like proportions.
Simple Solution: HM
How do we avert such a natural disaster? I see front-line clinicians—yes, hospitalists—leading the way. Hospitals and healthcare networks are actively mobilizing to create accountable-care organizations (ACOs) in preparation for payment reform almost certain to resurrect some form of capitation or bundling. The finance department of these organizations can only do so much. As they feel the tremors of financial instability, they will cling to what they know—increasing revenue through new services and budget line-item reductions (e.g. decreased funding for hospitalists).
These are short-term solutions at best, and your HM group might already be experiencing the after-effects of such activity.
Hospital administrators will tighten the financial belts, but they cannot improve clinical quality by reducing waste. To paraphrase Atul Gawande, doctors must cap their own pens if we are to reduce waste in the system. Value, then, can only be defined at the bedside in the context of a healthy physician-patient relationship. And as hospitalists, we are at the bedside of the most expensive decisions in medicine.
Although the future landscape might seem bleak, opportunities for HM are aglow with promise. We have the best view of how the system might make the biggest gains. We have been raised with a focus on quality. Scores of improvement success stories are told annually at our national meetings. If we can shift our conversations to improving quality while lowering costs, I believe that defining value will prove to be our field of dreams. TH
Dr. Shen is medical director of hospital medicine at Dell Children’s Hospital in Austin, Texas, and The Hospitalist’s pediatric editor.