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Sunday, November 7, 2010

Positive Outcome Based Medicine

Perhaps this is just me being unique, but I am suspicious that preventative health care and core values created by Medicare to improve outcomes and reduce hospital costs really don't reduce costs. In fact, I believe they actually make costs go up.

Consider preventative medicine. It was attempted back in the late 1980s. This is where you encourage people to exercise and eat right and quit drinking and smoking, and in this way you prevent people from getting sick. You encourage them to visit their doctor for annual check-ups, and to get annual testing done.

The problem with this theory is that I've seen people who are completely healthy, who eat all the right foods, who don't drink, who never smoked, and exercise daily come into the hospital and get diagnosed with cancer, and have seen patients who eat, smoke, are obese and drink daily live to the age of 90. I've seen it both ways.

So you can see, how you live your life does not prevent you from getting sick. It might help, yet all the preventative procedures you'll be getting every year will more than offset any savings from the people who live longer from living well.

Now I think it's a good idea to eat right and exercise, yet I don't think it's a good idea to force people to do these things. I don't think it's a good idea to force people to undergo tests they don't need. Besides, it's not a good idea to treat everyone the same anyway. If I have no family history of heart disease, I don't think I should undergo the same extensive testing as a person who has both his parents and siblings die from heart attacks.

We have some people chanting that we eat too much salt, and they want to make laws that restaurants should use less of it. Yet then their food will not taste as good, and nobody will want their food.

Look at McDonald's and Burger King. Their food is terrible for you. If you go to those places you will not be getting healthy food. Yet that is the choice of the individual. If you want to eat unhealthy food, you have that right. If people didn't want unhealthy, great tasting food, they shouldn't be going to these places.

The same is true of core values. While I think the idea of analyzing data obtained from a hospital to create better clinical pathways to improve patient outcomes and save money is good in theory, I don't think it will save money. In fact, I don't even think it will save lives.

For example, where I work we have created standing orders for each particular diagnosis (DRG). For every person with pneumonia, for example, we make sure that every one of those patients gets an antibiotic within six hours, smoking cessation offered if needed, a flu vaccine, and the pneumonia vaccine.

Yet, to make sure the patient meets criteria for admission so the hospital is reimbursed, to meet intensity of service, we also make sure the patient gets IV antibiotics and breathing treatments. Of course all of this is beneficial for some pneumonia patients, but most of these things are not necessary for most pneumonia patients. Therefore, there is overkill here. Overkill means wasted procedures being ordered that cost the hospital money.

Yet since most of these procedures and tests and medicines are considered safe, what's it going to hurt giving these to all patients. Basically, if you shoot a duck with ten bullets, maybe at least one will hit the duck. The bullet may not kill the duck, but at least we look like we are trying to kill it.

The same can be said of order sets and bundles where we treat every patient the same. We shoot that illness with everything we've got that we deem safe, and hope something works. At least the patient will be discharged eventually, and the hospital will get paid.

Yet since we are shooting so many bullets, since we are shooting 10 bullets when only one was needed (if one was needed at all), that's at least nine bullets that were wasted. That's nine bullets we had to pay for that weren't needed.

That's the way preventative care and order sheets work. Core values are good, preventative measures and order sheets are terrible. They are nothing but an incentive for doctors to order a bunch of stuff that's not needed, which, to me anyway, is wasteful spending.

I think, instead of preventative care, instead of order sheets, a hospital would be wise to take on a different approach, which I like to call positive outcome based medicine. Basically, this is where you do what works, and don't do what doesn't work. You do what's needed, and you don't do what's not needed. This truly would result improved outcomes and reduced costs.

To do this, I think, you would need to create bundles and protocols. The bundle would initiate all the procedures that might help that patient, and then the bundles would make sure what works is continued, and what's not working is stopped.

For example, since most patients might benefit from an antibiotic given, then give all pneumonia patients an antibiotic. Yet once you learn the patient does not have an infection, stop the antibiotic.

Since a certain percentage of pneumonia patients are also having bronchospasm, give all patients diagnosed with pneumonia a Ventolin breathing treatment. If the treatment works, continue giving them. If it doesn't work, stop giving them. Do what works, don't do what doesn't work.

Basically it goes like this:
  • Order sets do not save the hospital money because they treat all patients the same
  • Protocols do save the hospital money because they make sure what works is done, and what doesn't work is not done.
When it comes to eating right and exercising, I think it's better that I decide for myself to do those things. I don't think someone should be forced to. If the next guy wants to smoke and drink and eat poorly, that's his God given right.

Likewise, when it comes to treating patients, I think doctors should be encouraged to do what works for that particular patient, and not to treat all patients with a given diagnosis the same.

I think doctors, nurses, and respiratory therapists should be encouraged to use their skills to the benefit of improving patient outcomes and improving costs. I think protocols will do just that.

I also think each hospital should be encouraged to create clinical pathways to improve patient outcomes, yet I think each hospital should be encouraged to find their own clinical pathways. By forcing all of us to do it the same way, you are stifling creativity.

A good example here is the National Recovery Act of 1933. This act encouraged all businesses to set prices, products and to even set wages. The result here is all those in a particular industry were forced to do things the same way.

This Act actually falsely raised wages while productivity and competition were down. FDR did whatever he could to set higher wages. He wanted higher wages to give people who were working more purchasing power so they would buy more goods and services. FDR actually believed this would help end the Great Depression.

If this would have been passed in the early 1920s, and if Henry Ford were forced to produce cars the way every other car company produced cars, then the assembly line never would have been invented.

If in 1980 computer companies had set the price of computers at $1,000, few would have been sold, and the innovation that eventually led to the Internet would have been stymied. People would have to work harder to learn, and that would have led to even fewer innovations, such as no GPSs and iPods and other great inventions. We never would have seen the Internet bubble.

So encouraging everyone to do something the same way discourages innovation, and it does not always result in cost savings.

Yet the way things are designed right now in the medical field, since the government is forcing -- or strongly encouraging via programs that allow Medicade to refuse to reimburse hospitals if Intensity of Service is not met --the hands of the many smart and good people responsible for creating and improving clinical pathways, many hospitals are not "improving" the way that 90-100% success rate might be indicated.

And the difference between we think we see and actual improvements in outcomes and savings can be the difference between an organization (hospital in our case) succeeding or failing. And the difference is essential to you and me, because we want our local hospital to stay in business.

Yet interference by the government is leading many hospitals to failure, as we can see by all the small hospitals closing shop, and even some larger hospitals feeling the pain and plunging into a merger they once though would never be necessary.

Note: I am going to write several posts between now and February, 2011, about Core Measures, Intensity of Service and reimbursement criteria. Once those posts are published, I will republish this post and hopefully you guys will have a better understanding of what was written here. Perhaps you can use this information to better your institution. Yes I have become privy to such esoteric wisdom, and I will share it will you.

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