When you do the math, you can rather quickly determine that, as the aging process continues with the Boomer generation, federal funding for health care and Social Security will become more and more scarce. At the same time, we have all read the sobering national statistics regarding unnecessary deaths from hospital missteps. The CMS (Center for Medicare and Medicaid Services) previously introduced a form of pay for performance, or –more accurately– no pay for performance, which has already caused a great deal of change in the American Healthcare System.

As is widely known by now, CMS has decided to literally stop paying for the treatment costs of preventable medical complications.  This actually may seem like an intelligent idea. This approach is referred to by some as visibility for good care, and there is no doubt that it will represent the beginning of a stampede from the third-party insurance payers to follow the CMS “Big Dog.”  In fact, several companies have already announced that they will not be reimbursing hospitals for similar errors, as well.  The truth of the matter, however, is that this step does not even begin to address the problem.

The problem is not about penalizing hospitals, it’s about creating an incentive system that is not disease and sickness based.  Until the pyramid is flipped, we will not see the necessary changes to halt this financial slide to economic oblivion.

Sanjay Saint, MD, MPH

About 9% of U.S. hospitals presently use daily reminders to help physicians remember which patients have urinary catheters in place.  According to the University of Michigan’s Sanjay Saint, a professor of internal medicine, about 74% of hospitals don’t keep tabs on how long the catheters are in place.  But the real issue is that about 98% of hospitals and physicians don’t completely address issues of wellness and prevention that can allow us to remain well until we die because there is little or no incentive to do so.

Logic would dictate that because financial reimbursements will be connected to these hospital-created mistakes, infections or injuries, someone will surely pay more attention to the current misses.  But what if the entire system was based on keeping people healthy?  What if all of our focus was on exercise, appropriate food consumption, and stress management?

Unfortunately – or fortunately, depending upon your perspective – the United States has become the most proficient country in the world when it comes to capitalism, and much of capitalism is based on manipulating people to get them to consume what will bring the financial success and rewards to the corporations.  If you doubt this, just go to Eastern Europe to see what is happening in an environment with unregulated tobacco advertising.  The circle has started all over again.

In the old carrot-and-stick arrangement, there will be plenty of hits.  Wouldn’t it have been interesting, though, to reward hospitals where mistakes are almost nonexistent so that the less successful medical centers might line up to learn from them, or to reward docs and hospitals for helping to keep people healthy all the time. Carrots work, too, and with much less grief.

What’s the old line?  “We’re going to beat the troops until morale improves.”

Back in the 70’s, competitive marching bands came into vogue in Western Pennsylvania. Let me explain the before and after of this phenomenon: Before there were competitions, bands were made up of nearly 10 times more students than they typically have today. My bands ranged in size from 120 to 185 students. Once competition came into play, the borderline students were not able to survive. Consequently, it is not unusual now to have 20 students or less in a band.

What’s happening in medicine and in health care overall? The Government is taking a three-pronged approach to improve quality in health care:

1. They are pushing quality through public reporting. (Check a website near you.)

2. Enforcing quality through the False Claims Act. (Check a prison near you.)

3. Incentivizing quality through payment reform. (Check a checkbook near you.)

Senator Chuck Grassley is quoted as saying, “Today, Medicare rewards poor quality care. That is just plain wrong, and we need to address this problem.”

HMO’s are currently embracing “pay for performance” plans for physicians and hospitals. Medicare is introducing value-based purchase plans. Medicare is proposing the linking of quality outcomes to physician payments.

As I have written before, hospitals will no longer be paid for hospital acquired conditions. That seems like a rather simple fix, but to appropriately determine if the condition was not acquired at the hospital, extensive testing must be added pre-admission at considerable costs to the hospitals.

James G. Sheehan, Medicaid Inspector General of New York said, “We are reviewing assorted sources of quality information on your facility to see what it says and if it is consistent. You should be doing the same.”

Except for the financial implications, not unlike my competitive band story, the goal was to work toward perfection. The public reporting of quality of care is intended to:

1. Correct inappropriate behavior

2. Identify overpayment’s

3. Deny payments

The False Claims Act, on the other hand has different goals. When asked how he viewed the False Claims Act, Kirk Ogrosky, U.S. Deputy Chief for Health Care Fraud said, “You will see more and more physicians going to jail.” I guess the prisoners will be receiving better care.

Where’s it all going? Competitive band. Will it improve health care delivery? Probably, for the patients who can find the few docs and hospital that will be left? I recently had a conversation with a young computer specialist who took care of physician practices. He said, “Doctors and hospitals haven’t figured it out yet, but they are simply becoming data entry centers for ‘Big Brother’ as the facts and figures are accumulated to be used against them any way the payers decide to move forward.”

Looking back at the school year that included gym class twice a week for the entire year, rich courses in music and art, and remembering a time when priorities included those classes intended to make every student well rounded, we have to ask, “Is education today better?”

Maybe this is all too complicated to get our arms around, but if there are 78 million Baby Boomers, and the Medicare Trust Fund is heading toward bankruptcy, then we probably will see every rule in the book being applied to keep from paying out money, because there is simply not enough money to go around.

Will health care improve? Once we understand that technology is not the end all and cure all that creates healing; once we endorse prevention, wellness, optimal healing environments, and systems approaches to health and wellness, health care will improve. I’ll bet you that it will have very little to do with the rules that are unfolding right now and much more to do with the creation and acceptance of a National Health Policy.