Health Care

The Lowell Sun has an OpEd by Mary Anna Sullivan, who, along with her husband, sold us their wonderful home on Mansur Street. Thank you, Dr Sullivan.  The subject is health care.  For a while the Opinion Piece can be found here.♠

Because of the vagaries of the Internet, and the value of the article, I quote it in full here:

The medical model for best quality and low cost

The Lowell Sun
Updated: 08/19/2009 06:40:43 AM EDT

By Mary Anna Sullivan, MD

As the debate over health-care reform rages this summer, and recommendations are made as to how best to deliver quality care to all while containing costs, more discussion needs to focus on how we organize and deliver care.

Under the current model, multiple providers can order lots of costly tests for a patient and perform procedures, even if there is little evidence to support the intervention.  We pay providers to do more, even when "more" is questionable or redundant. Some assume incorrectly that high cost leads to high quality.

An efficient, successful model for care is the integrated group practice, a tried and true, organized strategy that enhances delivery and contains costs.  Integrated care networks are doctor-led -- not insurance-dictated -- and coordinate primary, preventive and chronic disease care for a patient through a primary care physician.  In a system like this, individual providers are not paid according to procedures performed or tests ordered; instead, providers receive a salary from the hospital or network.

There is no incentive to test more or do more in order to gain more financially.  The system's foundation simply harnesses the collective medical knowledge from all of the patient's providers to deliver a cost-effective, evidence-based, high-value outcome.  Because the primary-care physician coordinates care, and the medical record is shared, redundant tests and the frequency of office visits are reduced.

Thus, this model averts delivery fragmentation and the documented entrepreneurial spirit that fee-for-service inspires. Providers focus solely on practicing good medicine, even prevention counseling, something that has historically been underappreciated under fee-for-service.

Recent news accounts have singled out Mayo Clinic and Cleveland Clinic as examples of great, multi-group delivery as low cost. Locally, Lahey Clinic, a sister hospital, has operated in the same way since its inception more than 80 years ago.  Just like Mayo and Cleveland, Lahey offers high-quality care at lower cost and does exceeding well on nearly every health-care scorecard.  For example, Lahey is among the top nine hospitals in the country for low mortality after heart attack, according to the U.S. Centers for Medicare & Medicaid Services.  The Dartmouth Atlas ranks all hospitals across the country; Lahey ranks highly along with Mayo and Cleveland, uniquely among Boston teaching hospitals that deliver care in a much more costly way without improving quality.

When last year The Boston Globe published a series titled "A health-care system badly out of balance," it featured Partners Healthcare hospitals (MGH and Brigham and Women's) that are paid more by insurers for identical services provided at other Boston-area academic medical centers. In their analyses, the newspaper concluded the Partners' care -- which is fee-for-service based -- was "often no better than average."

Arguments have been made that if doctors have access to expensive technology, oversupply of specialists, and abundant inpatient beds, they will be used and will drive up costs.  This is true, but it is not that simple.  It is the system of delivery that should be examined more closely because that will have a more lasting effect on quality and cost, without sacrificing either.  Integrated group practices reduce perverse incentives and put focus back on the physician-patient relationship, our greatest hope to rein in spiraling costs while preserving what is best about American medicine.

Dr. Sullivan is chair of the Department of Psychiatry and Behavioral Medicine and chief quality and safety officer at Lahey Clinic Medical Center in Burlington.

In my humble opinion the debate is wrongly focused.  It should be about "Health Care," as opposed to "Health Insurance."  Think about it as the delivery system.

Part of my concern is that people will be greatly disappointed if the proposal before the House of Representatives passes.  The reason is that the actual delivery will not much change, given that we are not expanding the delivery system, either in breadth or in depth.  By breadth I mean we will not have extra folks to go out and meet the needs of those isolated from the current delivery system, because they live too far away or have had no insurance or lack the necessary cultural understanding of how to exploit the delivery system to meet their needs.  By depth I mean that we may well be contracting services to some degree, due to the increased demand (increased expectation of service), without an increase in delivery capability.  We are heading for a train wreck.

Regards  —  Cliff

♠  Note that since this is a link to an article in The Lowell Sun, it will likely expire in 30 days.  I will not be updating the link at that point unless I am shut in with the Swine Flu.