Attached is an article from JAMA in April 2012. Donald Berwick is the grandfather of quality in health care—he used to be CEO of the Institute for Healthcare Improvement and Administrator for CMMS. Andrew Hackbarth is a scientist at RAND.
Summary: The current trend in US healthcare expenditures is not sustainable. Reducing 6 common sources of waste can get expenditures down to where they are manageable for the foreseeable future and would save more money than reducing benefits.
Jim’s comment: Emergency Medicine, although representing about 12% of the healthcare budget, is an easy target for many of these areas of waste. CNMC is starting to see retroactive “take backs” of Medicaid money from Maryland and DC for ED visits dating back to 2010. These will increase in the future.
Potential areas of waste applicable to emergency medicine (surprise—it’s all 6):
1. Overtreatment. How often do we expose patients to unnecessary diagnostic tests and medications? The evidence would suggest that this occurs at least 20% of the time.
2. Failure of care coordination. How often do we fail to discuss a case with the PCP to pursue a well-coordinated strategy? How often do we pass off responsibility for care coordination to the subspecialists rather than manage the complexities ourselves?
3. Failures in execution of care processes. How often does our system fail at follow-up? How often do we fail to use known, evidence-based approaches to care that are effective and efficient? How often do we expose patients to harm as a result of failure of team function?
4. Pricing failures. How long can we continue to charge ED prices for urgent care levels of care? (we are working on this)
5. Administrative complexity. How much time is wasted documenting on patients with minor illness? How much administrative time is spent checking charts and billing for services that could more easily be a single sum payment rather than using the CPT system.
6. Fraud and abuse. Although I know this doesn’t happen at CNMC, I am convinced that private practice groups routinely order too many tests and treatments in order to drive up their billing levels. I believe the CMMS folks will take care of this with good data systems.
Enjoy, and be thoughtful about our practice.
Great points on the costs of care. A lot of it seems related to system-issues rather than being provider-specific. For example, over-treatment might be alleviated if there was better follow-up or integration of care. Same for care coordination. I agree that our current costs are unsustainable and a solution requires much more than deregulation and a free-market only solution. In fact, I would argue that more thoughtful integration--rather than less--would improve both costs and quality.
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