The Evolving Health Professions and Paying for Better Outcomes
As I write this From the Editor (April 2017), while Congress is finding it hard to reach consensus on how to improve health care in America, the one thing we all can agree on is that the fundamental problem that is afflicting our health system is ever-rising costs. There are many sources of rising costs: increased costs of new (and old) technology/pharmaceuticals, ever-rising unit prices of individual health services such as hospital stays, an aging population, to name a few.
I would like to suggest that changes in health care professional roles-the theme of this issue in our 40th anniversary of the Journal-have only just begun. With the outstanding set of commentaries that are included, I believe that all the possibilities for changes are laid out (famous last words
). By that I mean that with Kate Lorig's commentary, together with that of Brownstein and Rosenthal, this issue of the journal highlights the incredible role of patients/their families. In addition, Brownstein and Rosenthal with their focus on community health workers point us to the importance of the community in any sustained effort to improve health throughout a geographic area.
But to improve health and impact the health professions, we need to acknowledge that there are those who prioritize expanding coverage-including protecting the coverage for the 24 million covered under the Accountable Care Act. Others focus equally understandably on the need to cut health care costs. Both are searching for an approach that can strike a balance and address both objectives. Focusing for the moment on Medicaid, one way the federal government and the states could work together is to articulate a simple message-pay for better outcomes to help control costs. The federal government together with the states needs to consider that there are 4 system components, some to be sure controversial or cutting-edge, that promote a pay for better outcomes approach that can make the delivery system more efficient, thereby allowing considerations of ways to cover more individuals:
a. Clinically credible risk adjustment that encompasses all populations so that, for example, people who are disabled with major heart complications associated with diabetes are placed into a separate category from diabetic patients who are not as disabled from heart complications. Part of this risk adjustment process must recognize the impact of socioeconomic disparities and be sure that health care professionals/providers are not discriminated against because they are taking care of patients such as low-income schizophrenic patients who have diabetes.
b. Capitation of all services using the type of clinically credible risk adjustment outlined earlier and described later in more detail. This includes the payments that the federal government makes to states for the Medicaid program. We need to link financial incentives to improved outcomes. More details on this controversial idea are described below. As we've discussed a number of times in this blog, there are 5 outcomes that can be translated into dollars. Together, they account for Majority of services that are potentially preventable.
1. potentially preventable admissions (eg, diabetes out of control),
2. potentially preventable readmissions (an infection necessitating a hospitalization occurring several days after discharge for a hernia operation),
3. potentially preventable outpatient services (eg, preventable magnetic resonance imaging for back pain or operations for back pain),
4. potentially preventable complications (such as pneumonia occurring several days into a hospital stay for a patient hospitalized with a stroke),
5. potentially preventable emergency department (ED) visits (such as a visit to the ED for a cold).
c. Financial incentives to decrease these potentially preventable events must be accompanied by regular and detailed reports detailing opportunities for improvement in the aforementioned 5 types of potentially preventable events (collectively refer to as PPEs).
What are the controversies? There are several new approaches that challenge the status quo in innovative ways.
While the status of the American Health Care Act is unclear, the need to address payment reform, especially Medicaid, remains. Will this innovative approach be perfect-for sure not. There are other issues, not the least of which is the skyrocketing costs of pharmaceuticals; this can be addressed at least, in part, by a pay-for-outcomes approach. But if the federal government together with the states focuses on attempting to build on a decent society, one that strives to provide health care coverage for all its citizens, as many leaders are claiming as their platform, then the time for pay for better outcomes and cutting down on waste and inappropriate care is truly now. The key point for this issue of the journal is that health care professionals will ineluctably change in response to these better outcomes.
The remainder of this Journal highlights important issues that we continue to expound on in the Journal. We include articles on dental health (a truly undeserved area of research in general, and we are pleased to include this article by Norwood et al), the impact of sociodemographic factors such as race (Foo), and other important articles pertaining to individual caregivers and the patient-centered medical home.
-Norbert I. Goldfield, MD
Editor