Modern Healthcare reports that hospitals are increasingly hiring major healthcare-staffing companies as general contractors for institutions trying to keep supplied with contingent physicians and nurses.
The publication wrote: “Some hospitals say that working with staffing firms under the so-called managed-service provider model has helped them cope with severe shortages, and that MSPs have served them better than having to deal directly with individual staffing firms to locate and place candidates. MSPs can be used by healthcare providers to cover themselves in a variety of situations, from simply filling slots for a certain shift to flexing up during a massive system overhaul such as an information technology installation. ”
“Some hospitals and health systems are turning to the MSP model so they don’t have to dedicate as much time and resources to finding qualified professionals. Under the model, they outsource the role of dealing with staffing firms, letting the MSP handle not only recruiting, but sometimes also credentialing. MSP proponents say this allows hospitals to focus on providing care for patients, rather than scouring staffing firms for potential candidates.”
Here’s a look at two conflicting narratives used to explain surging medical costs: The patients as culprits because they overuse healthcare because much of it is “free” to them because of insurance and physicians and hospitals as culprits because they seek ever-higher revenue and personal wealth.
The authors conclude:
“{T]HE twin demeaning narratives of moral failure—by individual patients according to conservatives and by caregivers according to progressives—continues to animate health policy and drive us toward simplistic marginalist economics solutions that reduce physicians and patients to merely economic actors.
“The real story of what creates health and drives health spending is far more complex than these cartoon narratives suggest.
“We need a more complex and balanced explanation of what creates health, and a more comprehensive set of solutions that implicate public health and the human services, as well as individual citizens and the care system. The care system by itself cannot improve Americans’ health.”
We were pleased to read this essay in Modern Healthcare by David L. Brown, M.D., chief executive and co-founder of Curadux, a healthcare decision-support firm that’s partnering with Cambridge Management Group in some projects.
Americans dealing with advanced illness are at risk of overtreatment and undertreatment of their conditions because powerful and silent incentives are often driving their healthcare, rather than their own unique values and goals. After 38 years of practicing medicine inside the world’s elite healthcare institutions, and as a survivor of my own advanced illness, this is my foremost concern for current and future generations of patients and their families.
For those serving inside modern medical institutions, these risks are well known. As one caregiver recently told the Institute of Medicine, “When you take the time to find out what’s most important to patients and families, they make very reasonable choices. The challenge is that our healthcare system does not encourage these conversations, our professional providers frequently do not have the time or training, and treatment measures default to those that are health system centered.”
Healthcare is not always patient-centered because our third-party payer system disrupts the normal buyer-seller relationship we often take for granted. In healthcare, for reasons of public policy, the consumer isn’t always the paying customer for the services they consume, which distorts incentive structures throughout healthcare (and not always for the patient’s benefit).
Overtreatment — treatment that is unnecessary or futile for improving a person’s quality of life—is the dominant problem today. It may cause unwanted, invasive and expensive care, as well as unnecessarily prolonged and painful deaths. Health systems are subtly incentivized to overtreat patients because they generate more revenue based on the volume of services provided. Physicians are incentivized to recommend more services because they want to minimize perceived risks to patients and their own legal liability. Without clear guidance to the contrary, physicians default to treating a condition, often no matter how futile or painful for the patient.
Undertreatment — the lack of necessary treatment for improving a person’s quality of life — is the emerging problem. Policymakers are seeking ways to control healthcare costs as governments bear more financial responsibility for healthcare due to an aging population, the expansion of government programs, and increased consumption of healthcare by individuals. Since policymakers can’t change demographics and since a policy decision has been made to expand programs and subsidies, the primary option left for policymakers is to limit consumption of services.
Like most service industries, healthcare providers have traditionally been paid fees for the services they provide. Healthcare is unique, however, because the third-party payer system eliminates the natural market mechanism for limiting consumer demand and optimizing the quality and quantity of services around the perceived value to the consumer. At present, without a meaningful limit on consumer demand, providers act in their self-interest and deliver higher volume of services, which generates more revenue and increases costs.
To control costs, whether wise or unwise, policymakers opted against moving toward a market-based model whereby consumers assume more responsibility for healthcare and, instead, expanded the current system. They are now testing an artificial mechanism for controlling demand by simply capping payments to providers through population-health concepts. While this may reduce costs, it creates the risk that providers may discourage healthcare services for people who may legitimately benefit from them.
To permanently realign healthcare incentives around the individual would require overhauling the entire system so market forces could naturally optimize consumption. This is unlikely because of legitimate public policy issues and the practical difficulty of overhauling established commercial, financial, and regulatory frameworks in a polarized political environment.
Today, patients must educate themselves and stay actively involved in aligning their values and goals with their healthcare decisions. Primary-care physicians traditionally led this process through end-of-life conversations, but as clinical production pressures and demands have increased, physicians have less time to thoroughly discuss and analyze each patient’s unique values and goals. Instead, physicians now often rely more on other staff to perform this function. While these staff can be useful, the rich expertise provided by experienced physicians is often lost. True patient-centered care for patients and families facing an advanced illness is clearly ready for further innovation.
Dr. David L. Brown has practiced medicine for 38 years. He recently retired as chairman of the Anesthesiology Institute at the Cleveland Clinic. He has also led the anesthesiology departments at the University of Texas M.D. Anderson Cancer Center, University of Iowa Hospital and Clinics, and Virginia Mason Medical Center, as well as serving as professor of anesthesiology at the Mayo Clinic.
Health Forum convened a panel of healthcare executives and other experts on June 11 in New York City to discuss the intersection of population health and consumerism.
Key findings from the panel, as summarized by Hospitals & Health Networks:
• “As hospitals and health systems strive to become more consumer-friendly, they may need to rethink some common terminology, such as ‘patient-centered medical home’ and ‘discharge’ to reflect consumer sentiment.
• “Population-health management does not mean an organization needs to provide all things to all people. Instead, hospitals and health systems should focus their efforts on providing preventive care and wellness to certain populations, such as patients with co-morbidities.
• “Price and brand are top of mind for consumers. However, consumers are willing to go out of network for services if they find poor ratings among in-network physicians. Other important considerations for consumers are convenience and wait time.”
We just received this press release from a Cambridge Management Group friend, David L. Brown, M.D. We’re very happy to read this exciting news:
Curadux has pioneered a new healthcare decision guidance model for individuals and families facing advanced illness
AUSTIN, Texas
David L. Brown, M.D., the former chair of the Cleveland Clinic’s Anesthesiology Institute and a recent survivor of his own life-threatening illness, has announced the launch of Curadux to help patients and families facing advanced illness make wise decisions and avoid overtreatment and undertreatment of their conditions.
“Americans facing advanced illness today are at risk of overtreatment and undertreatment of their conditions because powerful and silent incentives are often driving their healthcare, rather than the patient’s own unique values and goals,” Brown said. “After 38 years of practicing medicine inside the world’s elite healthcare institutions, and as a survivor of my own advanced illness, this is my biggest concern for current and future generations of patients and families. This is why I’m excited to launch Curadux and help solve this problem .”
In 2014, the Institute of Medicine released a landmark report highlighting the unfortunate reality that many Americans aren’t living well in advanced illness. The current health system incentivizes overtreatment which may cause unwanted, invasive, and expensive treatments, as well as unnecessarily prolonged and painful deaths. In the words of the IOM, “the default decision is to treat a disease or condition, no matter how hopeless or painful.” Undertreatment is an equal concern as policymakers, in their quest to reduce healthcare costs, begin to cap payments to providers which may incentivize the minimization of healthcare services for people who may legitimately need them.
Curadux solves these problems by establishing a new functional role called a “Care Guide,” staffed by experienced physicians who are solely dedicated to helping patients and families align their unique values and goals with their healthcare decisions, independently from healthcare payers and providers. Care Guides help patients and families to thoroughly assess their values and goals, understand the detailed implications of their options prepared by their medical teams, and ultimately document their healthcare decision, while also alleviating pressure on their primary care physician.
For years, Massachusetts has been out in front of other states, trying ideas to change the health system. It passed a state law extending health insurance coverage to almost all citizens four years ahead of the federal health law, and then the commonwealth tried to tackle rising health costs.
But the latest numbers are disappointing: Massachusetts spent $632 million more on health care last year than it aimed to, according to a report from the state’s Center for Health Information and Analysis.
The goal, established by a 2012 law, is to keep health care spending in line with the rising costs of other goods and services. Every year the state sets a benchmark. In 2013 — the first year of accountability under the law — Massachusetts stayed well under the cap on health care cost growth. But last year, spending shot right past the 3.6 percent target and hit $54 billion, a 4.8 percent increase over the previous year.
“It’s far above the rate of inflation that we’re seeing in the state. It’s far above what family incomes are going up at, and far above what small businesses are seeing in their increased sales,” said Jon Hurst, president of the 3,600-member Retailers Association of Massachusetts.
So what happened? The big jump was at MassHealth, the government insurance plan for low- and moderate-income residents. MassHealth added 379,000 members and saw spending rise $2.4 billion, or 19 percent. Some members became newly eligible through the Affordable Care Act, but most, about 325,000, were automatically enrolled in the months after the Health Connector Web site crashed.
“Obviously the 19 percent growth in MassHealth is distressing to all of us,” said Marylou Sudders, the state secretary for health and human services. “And this administration is taking steps to redesign and restructure a MassHealth program that is sustainable for the long haul.”
Sudders aims for a 6 percent budget increase this year.
There are signs that the influx of MassHealth members may be temporary. Through an eligibility review, MassHealth has reduced enrollment so far this year by 205,000 members.
But where did all of those new MassHealth enrollees come from and where will they get insurance now that they’ve left? No one seems to know. Private insurance plan membership did not drop significantly last year and the state claimed to have few residents without health insurance.
“There’s much more going on here that we don’t understand,” said Stuart Altman, who chairs the board of the state’s Health Policy Commission. “We need to dig deeper and find out.”
Altman said the commission will also look at a 13 percent rise in drug costs highlighted in the CHIA report. But there’s not much one state can do to curb drug prices, Altman acknowledged.
“You can make sure that only those people that really need the drug get it, but of course that can be quite controversial,” Altman said. “And one needs to look at whether there are tradeoffs between more drugs and less services.”
In the private insurance market, premiums rose more than the year before, but the increase remained modest, at 2.6 percent. The CHIA report says employers and insurers kept premiums low by switching to plans with higher deductibles or by changing co-payments.
“The purpose of insurance is to protect people from out-of-pocket expenditures and so that’s a trend that is worth watching,” CHIA Director Aaron Boros said. “Massachusetts tends to have less use of these products than any other state, but it’s growing faster than any other segment of the market.”
This report, with some troubling signs for health care spending, comes a week after small businesses learned that the base rate increase for premiums will rise more than 6 percent at the beginning of next year.
“We are seeing an acceleration of health care spending,” said Rick Lord, president and CEO of Associated Industries of Massachusetts, a membership organization for businesses. “It’s too early to predict whether this trend will continue, but it does look like next year premiums for small employers will be more than double what they were in 2014.”
So is the state’s health care cost law working? Does setting a yearly spending goal help?
“This is just a never-ending battle,” said Hurst, of the retailers group.. “We cannot continue to drain money from our consumers, employers and taxpayers and shift it over to the health care industry.”
But, health secretary Sudders said, “We’re not going to always hit the benchmark, but what this [law] does is it continues to put a very public spotlight on our need to control costs.”
“Whether or not it’s working to dramatically change behavior is much harder to tell,” added Boros. “We do have some indications that commercial health care spending is rising faster and faster, especially with the introduction of new technology and, in particular, prescription drugs.”
“My sense is that the people who provide care have been very conscientious about trying to lower spending,” said Altman, who has been studying health care costs since the late 1960s. “The law is having an effect.”
One last figure of note from the report: $8,010 is the average amount of health care spending for each resident of Massachusetts last year. The report’s authors say few, if any, states spend more.
This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.
Mr. Kaufman said that the “telecommunications and media industry has notable parallels with health care. In many regions, the hospital market is saturated, increasingly leading to commoditization and competition based on price. Skinny bundles {of services like those newly being offered by an increasingly nimble Verizon] are a familiar concept in health care, with payers and employers developing narrow networks of providers that are able to deliver high quality at low prices. In health care as in cable TV, consumers are showing dissatisfaction with high costs and lack of flexibility by going over the top of traditional health care organizations and accessing care from sources such as retail pharmacy clinics and telehealth companies.”
“….Verizon’s actions show that when a strong organization recognizes a changing environment, commits itself to being a major force in that environment, and is willing to disrupt the status quo, legacy status can be a tool for continued relevance.”
“We do, indeed, ration health care in the United States; we just don’t talk about it, with the result that we ration it altogether irrationally. There is almost no limit to what we will, and routinely do, spend on the often desperately futile care at the very end of life in very elderly people with multi-organ-system failure, a long history of serious chronic disease, and virtually no chance of getting back to a quality of life any of us would be willing to accept. But we routinely fail to cover the costs of effective preventive services that can save both lives and money, and impose substantial barriers in the form of co-pays and deductibles on care that is essential.”
“At the peak of attention to health care models, before the Affordable Care Act came off its assembly line, colleagues and I published a proposal for a tiered model. We suggested that certain varieties of care — both effective preventive services, and urgently needed treatments — should be available to all with no financial barriers. A tier of services of slightly lesser value or need could be available to all, but might reasonably involve some barriers in the form of co-pays. Finally, a tier of quite discretionary services might come entirely out of our own pockets. This is one example of potentially rational rationing.”
The Washington Post says Ellie “was born of two lines of findings: that anonymity can help people be more truthful and that rapport with a trained caregiver fosters deep disclosure. In some cases, research has shown, the less human involvement, the better. In a 2014 study of 239 people, participants who were told that Ellie was operating automatically as opposed to being controlled by a person nearby, said they felt less fearful about self-disclosure, better able to express sadness and more willing to disclose.”
But will the likes of Ellie mean fewer jobs for real clinicians?
The goal, established by a
