The Train Has Left the Station – Are You On It?

By  |  April 13, 2009 | 

Rob Bessler writes…

I am fired up. At the recent phoenix group meeting I attended we heard from a physician working for an organization funded by the American Academy of Family Practice Physicians that is spending 16MM dollars to fund this think tank and action oriented group focused on ensuring their voice is heard and that family physicians role in our future healthcare system are at the center. I applaud them for this effort.

What I left with from a few hours of education and discourse was how important hospitalists are to viability of whatever government based payment system occurs in the future. Of course I knew this from an academic perspective but now it is flowing through my veins. Did you know that medicare who ensures more than 40MM Americans spends 68% of the funding on 10MM of the recipients who average 11 doctors and 50 prescriptions per year! How about how little those 11 doctors communicate with each other? The average pcp in the community has to communicate with 50 to 250 specialists depending on the size of the community. This can’t work without an EMR system and hospitalists communicating clearly about the most crucial stage of hospitalization where the majority of the costs lie.  How about the fact that 18% of GDP is healthcare spending or that federal government based healthcare spending is the largest item in the budget, larger than even defense spending.

I have reached out to SHM through the public policy committee, volunteered to be more involved in the phoenix group as well as other groups like healthcare innovation 2009 to ensure hospitalists voice is heard and that we and our collective ideas to improve the patients hospitalization with high quality at a lower cost and the transition back to the outpatient provider happens not as a passenger but as drivers I envision that we  aligned with our hospital partners to finally have a payment system that rewards better outcomes. In the same way that the current the hip replacement specialists with the best and worst outcomes get the same fee today and that needs to change the same should be true for the hospital medicine field.  In some markets where Sound thrives, there are  colleagues we work along side that have no motivation to move patients through the hospitalization as it is considered a revenue loss to them while the hospital and potentially the patient suffer the effects. From the people whom I have spoken with it is not a question of if we will have a bundled payment with hospitals but when. Are you and your group prepared and on the train to drive value to ensure your hospital sees you as their partner to split up a payment?  I will blog from time to time with updates as I learn and discuss more on this very important subject to all of us. I am interested what you all know as well.


  1. Jairy Hunter, MD, MBA, FHM April 14, 2009 at 8:53 am - Reply

    It’s good to see someone else fired up and optimistic about changing the status quo as far as quality statndards, payments, and continuing the discussion between providers, hospitals, politicians, and (not least of all) patients. The issues you touched on–P4P, disincentives for timely discharges, and the the need for hospitalists to be at the forefront of change–are insightful. Hopefully, more stakeholders on all sides of these issues will understand that our concerns need to be dealt with in a forthright manner.

    Over the past couple of years as a hospitalist, I’ve come to the opinion that we will have to have some sort of universal coverage–the desire to provide at least basic care for all of our citizens says a lot about about our nation. And that doesn’t come solely from the fact that our collection rate is alarmingly low (I happen to derive most of my income from salary–although I acknowledge there can still be bias).

    I would say my own optimism, however, is more “cautious,” in that although things seem to be moving in the right direction, we really do need to stay abreast of developments and make our own particular hospitalist voice heard. With all these parties jockeying for position, it becomes easy for government and others to push physician concerns to a lower priority, especially given the apparent attitude of this administration toward what it sees as the drivers of the high cost of healthcare.

    I haven’t had an opportunity to review the healthcare proposals in detail since the election, but I did study Obama’s ambitious vision of what healthcare should address during the campaign. It was rife with the notion that “big insurance companies” were charging too much (and making too much), doctors were making too many errors and spending too much, and not enough people were gaining access. While each of these is founded, there are many more causes in addition. There was little or nothing about tort reform or the practice of defensive medicine, the inefficiency of government-run healthcare plans (the VA system, medicare, medicaid), and patients’ perceived entitlement to the latest and greatest in technology and procedures (and drugs), whether proven beneficial or not. There were also few details on the current P4P trend so that what someone in government uses to judge ostensible “quality” and “performance” actually reflects Quality and better Outcomes, which some would argue, currently don’t.

    I also happen to believe that the nature of competition in healthcare (services, insurance, and pharmaceuticals) needs to be addressed as well, but that’s an argument for another forum.

  2. Robert Bessler April 14, 2009 at 12:34 pm - Reply

    Thank you for your thoughtful response. At the end of the day whether people want to admit it or not the issue regarding Healthcare and its reform in this country is about money. Because of the recent recession and less payroll dollars in the US, the 1.45% from both the employer and employee to pay for medicare combined with the benefits / liability of medicare expanding ie not a fixed amount we spend as a year as more technology, expensive alternatives and people age occurs, the system will be bankrupt even earlier than 2018 according to the actuarial experts at Medicare.

    What I find equally fascinating is the country is not willing to engage in the discussion about death and limitations on care. Other countries can control costs by denying access to procedures after a certain age, but not in the US. This is a heavy duty discussion that no politician will get near as the largest voting block is those that this would impact most. Tort reform, limitations on access, and paying for quality outcomes vs volume all need to be addressed simultaneously.

    It is the belief of many including me, that the answer lies in personal responsibility. People can eat what they want, smoke what they want, yet the government pays the same for everyone. 10MM of the 45MM americans on medicare make use 66% of the medicare dollars. These 10MM citizens see 11 unique doctors per year and fill on average 50 prescriptions per year. The government funds can be used by given to patients to begin to make decisions that impact them. Give patients the money they don’t spend and have them question the utility of the yearly tests the same way i challenged my dentist ) why i needed xrays each year? Was it based in data, the answer was no. If i didn’t ask, it would have been done as “standard”.

  3. Rob Zipper April 18, 2009 at 11:57 am - Reply

    Great thread. Dr. Bessler, you bring up many issues that are major challenges with reform of our health care system. Our citizen’s insistence on entitlement to whatever medical procedures are available probably has roots all the way back in the war for independence from England. We have a culture of the individual, and an expectation of the best, regardless of cost. It is a romantic fantasy that has created a crisis, brewing for at least the last 30 or 40 years. After all, Nixon’s endorsement of the Kaiser model for HMOs was an attempt to control spiraling health care costs.

    The rise of consumerism, I suspect, will have the deepest impact on the way that Americans view their health care options. We are starting to see more of this already, in particular in those with high-deductible health plans. I have been asked much more than in the past how much things cost, and patients and families I think do have higher expectations than in the past. This will only increase as greater costs are shifted directly to patients.

    Within 5 years, it will be commonplace for patients to ask about costs of admissions, meds, etc. in the ER. Hospitalists will get cought up in this, which is somewhat unfortunate. We have all probably had a situation in which a patient or family member asks us, the hospitalist, whether the surgery that the surgeon has recommended is really necessary, but are we prepared to discuss the costs of procedures and alternatives? I suspect (and hope) that hospitals will create positions for financial counselors for patients to meet these needs. I can imagine a scenario in which a counselor gets called to the ED to discuss the costs of treatment for a patient requiring hospitalization for pneumonia, prior to the decision to admit being made. “This will cost me at least $10k? Maybe I will just take my chances with my antibiotics and oxygen at home, and come back if I don’t get better.”

    No matter what health care reform comes our way, as Dr. Bessler points out, Medicare is toast by about 2018 at our current rate of consumption. Outpatient PCPs are really in trouble, and we continue to support situations in which more care does not translate to better outcomes. We are, by necessity, going to see changes in “entitlement”, and the dreaded “R” word, rationing, will come up again. It simply has to, if we are going to improve our health care system overall and spend wisely to improve outcomes. Consumerism will open the door to those changes.

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