Data and leadership by healthcare finance experts will have the biggest effects on improving quality and cost control in the U.S. healthcare system, according to a leading healthcare researcher and quality improvement expert.
Atul Gawande, MD, a surgeon at Brigham and Women’s Hospital in Boston and researcher on cost and barriers to quality improvement, told attendees at ANI: the HFMA National Institute this past June that improving the care of and reducing costs for the most expensive patients show the way to improving the overall system.
“It’s still all about the sickest; what we do and whether our systems can care for the sickest in our society,” Gawande said about the 5 percent of patients who account for 50 percent of healthcare spending. “That’s how we fix health care.”
To improve clinical and financial outcomes for the sickest parts of the population, providers and payers have to change how the healthcare system interacts with those patients.
Initiatives, such as one focused on 100 of the highest healthcare users in Camden, N.J., found that teams of providers were needed instead of just one clinician. That initiative found problems were not identified by the many separate providers seeing a patient, such as the asthmatic patient who required repeated hospitalizations because no one ever taught him how to use his inhaler correctly. The same patient also benefited from nontraditional healthcare interventions, such as buying him a vacuum to help clean the air in his home.
“For these highest-cost patients we need entirely new systems and require entirely new investments,” Gawande said.
That is why new clinical teams focusing on the sickest will need the involvement, and sometimes the leadership, of healthcare finance leaders. Such professionals are in a position to push for financial incentives that reward providers for avoiding unnecessary care and pay for nontraditional interventions that are clinically effective.
Without motivation by hospital finance officials to change the incentives under which providers are paid so that they financially benefit when patients become healthier—and not from retreatment of patients whose care was poorly coordinated—”that discussion doesn’t even get started,” Gawande said.
Perverse Financial Incentives
That commitment by finance leaders may be complicated by factors that were identified in Gawande’s own research published last year. His study showed a hospital’s surgical profits increased 330 percent when there was a surgical complication because insurers pay hospitals to fix their own mistakes.
“It allowed them to go back to their insurers and say, ‘We need to make a different deal because we don’t want to be in this position; we want to profit when we make it go right, so we have to find a solution to be able to do that,’” Gawande said. Without the results of the study, “that discussion doesn’t even get started.”
The hospital in the study, Texas Health Resources, developed a deal with insurers according to which their payments would remain unchanged if they achieved a 10 percent reduction in errors. They ended up with a reduction of 15 percent.
“We’ll try to find out if we have made a system or an approach that has worked to solve this,” Gawande said, referring to final financial figures expected later this summer from the hospital’s new insurer arrangements.
Gawande emphasized that a crucial component in “flipping around” the financial incentives to reward high-quality care is a growth in such transparency.
Transparency in quality and cost outcomes can help drive the healthcare system toward improvement, with research having shown that often the best care is delivered at the lowest cost.
“When it turns out that the best care is possible by making it more like a system, more organized, avoiding complications, making more sense along the way, and that it ends up being among the lowest-costing, that is a tremendous opportunity,” Gawande said.
