We’ve always heard “a pound of cure” right? One of the constant refrains in health care
right now is the billions of dollars spent each year on “preventable” emergency
room visits, and “preventable” inpatient admissions, and “preventable”
readmissions.
Of course, we all know that many of the health care
conditions that plague America right now are, in fact, “preventable.” But that would involve fewer trips to
McDonalds and more trips to the gym, so we’ll leave that discussion for another
day.
For now, let’s look briefly at some new research that was
released this week about the value of an “ounce of prevention.” Unfortunately, it doesn’t look like it’s a
pound of cure. To set the context,
understand first of all that the “prevention” we are discussing here is not
more annual physicals, screenings, etc. that can be rightfully lumped into the
discussion about prevention. What we are
talking about today is prevention on the order of care coordination, improved
transition of care processes, population health management, and enhanced access
to care that could help keep people out of the ED, the inpatient bed, or
returning to the hospital after discharge.
The common notion right now is that if we could only get a
handle on preventable admissions, readmissions, and ED visits, we would go a
long way towards solving the health care fiscal crisis. And Medicare payment policy is already
heading in that direction by refusing to pay for what they deem to be
“avoidable” readmissions. So how much
potential savings do we have in the “preventable” market? A new study suggests it may not be as much as
health policy experts thought.
Released on Tuesday, a study
headed up by the now-familiar Dr. Atul Gawande threw a large wrench in the
commonly held assumptions about all things “preventable.” This
study took a representative sample of the Medicare population and identified
the top 10% of high-cost patients. What
they initially found about these patients was not a surprise, and that is the
top 10% of high-cost patients contributed to 70% of the costs of Medicare. This is not new news.
What is new is the study revealed that for the 10% high-cost
group only about 10% of their health care costs were “preventable.” This means that 90% of the health care costs
in the most expensive group – the very group of people that much of health
policy focus has been on with the thought that prevention of admissions for
these folks would lead to massive savings – are not preventable. Now the 10%
of preventable costs is still a lot of money, but much less than anyone in
health policy debates would have predicted.
In the end, this study turns a lot of assumptions upside down about how
much can be saved by doing a better job of coordinating care, redesigning care
processes to be more patient friendly, and taking the many other steps that are
being suggested to help prevent admissions to the hospital. This doesn’t mean that the efforts are
fruitless, it just means they may not lead to as much savings as expected.
So what did the study propose as a solution based on this
new information? The first is a
no-brainer, which is we have to do a better job of figuring out population
wellness, but the timeline for results in this area is at least a generation
out (and some would say that getting the public to change their eating,
exercise, and other lifestyle habits is near impossible). What about immediate results? Here is their solution: “[F]ocus on reducing per-episode costs for
high-cost disease entities through clinical innovation and care delivery
redesign.” Let me put that in plain
English: Since the bulk of Medicare
costs are not preventable even with best efforts, then physicians and hospitals
need to figure out a way to provide less expensive care. The study suggests bundled payments and ACOs
as a part of this solution. More to be
said about this later, but a complex issue just got much more complex with the
release of this study.
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