The F Words Of Wellness Care

Vassily Kandinsky, 1923

Fragmentation, Fee-for-service as well as Futile attention are the trifecta of what is supposedly ailing our wellness attention system, or non-system, as it is fashionably described nowadays. Modern wellness attention has reached its crisis request non due to hordes of people keeling over as well as dying inwards the streets, as they did during historical wellness attention crises brought on past times plagues as well as famine, but due to exploding costs of delivering decent attention to all people. Since the number at nowadays is generally financial, wellness attention as a plain of study is attracting the interests of those who exercise the dismal scientific discipline of Economics. Over the final 2 centuries, economists convey successfully addressed the F words inwards other industries amongst spectacular results inwards developed countries, as well as so why non apply lessons learned to wellness care? 

The obvious argue to care for economists amongst suspicion inwards wellness attention is the quintessential declaration that people are non widgets, but in that place is some other problem. Most tried-and-true solutions for increasing availability as well as character spell lowering costs of products are non accounting for the other explosion occurring as nosotros utter – the Internet.  How tin this assertion live truthful when nosotros are inwards the midst of a regime sponsored spending spree to computerize medical records as well as adopt Health Information Technology (HIT)? Apparently, fifty-fifty those who Pb as well as define the HIT revolution are reluctant (or unable) to grasp its total implication, hence they are consistently underestimating the might of the Internet to serve the individual, as well as as a outcome are hedging their bets on engineering scientific discipline amongst classic industrial models from days gone by.

In a 2008 Health Affairs article, Dr. Donald Berwick has defined what has move the official destination of policy making for the Secretary of Health as well as Human Services. Better known as the Triple Aim, the goals are to create amend health, render amend attention as well as lower costs of care. If y'all await at wellness attention as but some other industry, the Triple Aim translates into a amend production amongst a amend procedure at a lower cost. Well, when spot this way, the solution is pretty obvious as well as it has been obvious for over 2 centuries. We must address the F words: eliminate Fragmentation past times aggregating independent artisans inwards ane physical location, halt paying Fee-for-service (piecework) as well as pay salaries instead, as well as most important, eliminate Futile piece of job past times standardizing the process. In short, apply the industrial revolution to wellness attention as well as realize the economies of scale that brought prosperity as well as happiness to the developed world. Except that for some foreign reason, this solution doesn’t quite piece of job inwards wellness care.

Case inwards point: Federally Qualified Health Centers (FQHC). FQHCs started out inwards the early on 1960s as community run clinics to render medical attention to the poor. By the mid-nineties, as well as amongst the best of intentions, the Federal regime as well as the Centers for Medicare & Medicaid Services (CMS), created funding grants as well as reimbursement methods to back upward these clinics. Today in that place are thousands of FQHCs of dissimilar types, operating inwards wellness attention shortage areas as well as providing team-based comprehensive attention including preventative care, basic main care, behavioral care, dental care, lab as well as chemist's shop services, generally to Medicaid beneficiaries as well as the uninsured, but also to small-scale numbers of Medicare as well as privately insured patients. FQHCs must exercise mid-levels to render as well as coordinate attention as well as must written report on character measures. In return, FQHCs have millions of dollars inwards grants for edifice as well as improvements, convey access to toll effective workforce, tin obtain complimentary malpractice protection, are revenue enhancement exempt as well as are paid to a greater extent than than double what a private exercise is paid for Medicaid services. By all accounts, FQHC are addressing the triple Fs of wellness attention rather well, but how are they doing against the Triple Aim objectives?

Studies are mixed regarding character of attention provided past times FQHCs, as well as patients cared for past times FQHC are largely sicker than those seen inwards private practice. Interestingly enough, neither Medicare, nor privately insured patients are flocking to FQHCs, inwards spite of the fiscal advantages offered, especially to Medicare patients, as well as inwards spite of the spiffy province of the fine art facilities. This may, or may non be, an indicator for perceived character of care. How virtually lowering costs? Do FQHCs render attention at a lower toll than, say, an independent solo private practice?  Adding straight off reimbursement rates, grants, revenue enhancement breaks as well as other benefits, FQHCs visits toll to a greater extent than than twice the amount paid past times Medicaid to private practices, which cannot compete amongst FQHCs as well as all but disappeared from areas where FQHCs operate. What would convey been the results if xx years agone CMS would convey decided to growth Medicaid fees as well as pay for uninsured visits to independent practices, instead of only backing the creation as well as operations of a divide but equal clinic scheme for the poor? We may never know for sure.

FQHCs are only a small-scale example* of why economies of scale are non easily achieved inwards wellness care. Large infirmary organizations as well as fifty-fifty fully integrated wellness systems, which may live providing amend attention (or not) seem as incapable of reducing costs inwards spite of attacking all iii Fs, or seeming to do so, as well as in that place are 2 reasons for this failure: a) larger wellness attention facilities convey disproportionately larger overhead costs as well as b) large systems are amend equipped to accuse to a greater extent than for services, which renders their efficiency efforts less urgent. And this is non a affair of opinion. CMS acknowledges this built-in inefficiency as evident inwards the physician fee schedule which pays an additional “facility fee” for services provided inwards infirmary owned outpatient clinics, presumably to covert the extra overhead. Surprisingly, CMS is consistently creating incentives as well as regulations to accelerate provider consolidation into these large inefficient as well as expensive systems. The only possible explanation would live that CMS is betting that elimination of the final 2 Fs (Fee-for-service as well as Futile care) volition live easier inwards a consolidated surround as well as the gains volition ultimately overstep the losses from doing away amongst independent exercise (Fragmentation). What virtually information technology? Well, it is supposed to assist amongst procedure standardization, information collection as well as performance measurements, like to what computers do inwards every other industry.

We convey all seen the infomercials for high-tech hospitals, where a bunch of doctors are seated about a conference room table, each asset a laptop or tablet, presumably discussing patients inwards a squad environment. There is something really incorrect amongst these pictures. First, it costs us a fortune to convey all these physicians inwards ane room. Second, in that place is almost no added utility for them to live using computers instead of passing about a slice of paper, as well as computers are expensive. Third, in that place is no patient inwards the room. Now let’s imagine a dissimilar picture: a main attention physician sitting inwards his office, amongst a patient side past times side to him, both interacting amongst a reckoner on which a Skype conference is taking identify amongst an oncologist sitting inwards his ain move 30 miles away, a surgeon inwards a infirmary lounge inwards the metropolis as well as mayhap a radiologist one-half a continent away. Everybody on the telephone band has access to the same electronic medical record, appointments tin live made inwards existent time, literature tin live consulted as well as shared, prescriptions tin live changed as well as a mutual attention innovation agreed upon past times all as well as understood past times all tin live created as well as past times using intelligent predictive analytics tools diverse options tin live explored. Perhaps a identify unit of measurement fellow member inwards a dissimilar solid ground is conferenced inwards as well as mayhap the patient is at abode or inwards a intermission room at work. Perhaps there’s an electronic sign-up canvass for the oncologist, if the patient wants to enquire something else afterward as well as convey a physician friend inwards New Zealand nous in. And amongst ane click on a PayPal push clit all doctors are paid for their time.

In this Internet age, manufacturing vogue physical consolidation is non only unnecessary, it is toll prohibitive. Modern lifestyles as well as modern medicine convey created a require for doctors as well as patients to collaborate as well as the Internet is providing the agency to accomplish such collaboration without having to physically get together everybody nether ane expensive roof. There is no require to obliterate the operational efficiencies of private exercise as well as supercede it amongst the bloated bureaucracy of large institutions, as well as in that place is no require to dispense amongst long lasting doctor-patient relationships inwards favor of computerized attention coordination, as well as in that place is absolutely no require to substitute a bunch of numbers inwards a reckoner for a existent patient. The Internet is decentralizing as well as individualizing everything from politics to manufacturing. Health attention is, as well as e'er has been, decentralized, individualized as well as based on the local patient-doctor dyad. The resemblance is striking. We either encompass the fully aligned collaborative nature of the Internet to accomplish amend health, amend attention at lower costs, or engage inwards a doomed endeavour to impose an unnatural centralized command as well as command construction inwards wellness attention but because it worked good for 19 century steel manufacturing as well as because policy makers don’t really sympathize the magnitude of the connectivity revolution.

* According to the Kaiser Family Foundation FQHCs had virtually $12.7 Billion inwards revenues inwards 2010, 75% of which came from Federal as well as State agencies. They served almost 19.5 1000000 patients amongst over 77 1000000 encounters. Simple math yields a toll of unopen to $165 per encounter.