Friday, 28 March 2014

Wennberg: ten thoughts about chronic care

In Chapter 12 of his book "Tracking Medicine", John Wennberg reflects on how the American health system is treating chronic patients and, as I think it is a careful and timely analysis, I want to dedicate this post to comment these reflections.

First thought

Blind trust in hospital medicine does not work for the chronically ill patients

It is considered that Medicare spends 18% of its budget on hospital admission bills during the last two years of life of chronic patients. While it is true that overactive hospitals can add some days to the lives of chronic patients, the question is what is the quality and how big is the suffering... and at what cost.

Second thought

Sutton's law: If you are interested in saving money, have no doubt that the saving is to be found in hospitals

Willie Sutton was a bank robber, and when asked why he did it, he answered: "That's where the money is, right?". Wennberg proposes a strategy for implementing Sutton’s law in a less bleeding way: benchmarking. I mean, if you get the hospitals that admit more chronic patients to reduce these rates to levels of those hospitals who admit less, you could raise enough money for community programs more tailored to the needs of these patients, and also could really make a saving.

Third thought

It’s the quantity, stupid!

"It's the economy, stupid" is a phrase that has 57 million results on Google. According to Wikipedia, the judgment can be attributed to James Carville, an adviser to Bill Clinton’s presidential electoral campaign of 1992. Curiously, the same Wikipedia source says that this campaign also had another slogan: "Don’t forget health care." Wennberg tunes into Carville’s phrase to highlight that the amount of installed hospital beds in a territory is the main attraction for potentially avoidable admissions. Therefore, the advice is clear: eliminate as many hospital beds as possible.

Fourth thought

More hospices, outpatient care and home care in itself will fail to reduce potentially avoidable hospital admissions

The high prevalence of chronic diseases cause that the resources made available, whatever they may be, are used. Therefore, if you invest in community resources with an alternative intent, they will no doubt be used instead in a complementary way, but by no means as a substitute. According to Wennberg, the unique formula for progress is not investing in more resources but aligning the care objectives between hospitals and community services, and this can only be achieved through the coordination or integration of services (the latter much more advisable that the first action).

Fifth thought

If nothing is done, the tendency to increase hospital admissions is unstoppable

American statistics warn that the trends to improve hospital care for chronic patients and to technify the end of life episodes are unstoppable, and what is even more disturbing is that in the territories where the figures are higher, far from moderating, continue to increase even more than standard trends.

Sixth thought

The funding model influences, but it’s not essential

I understand that the statement goes against logic, but Wennberg would emphasize that more than the way in which providers are paid, the installed hospital bed capacity in a region has an influence upon the admission of chronic patients over the billing model. And for this reason, in "Tracking Medicine" Wennberg cites a work by Laurence Baker, an economist at Stanford, who examined the hospitalization rates for the last two years of life of chronic patients in California, according to four different types of payment models, ranging from direct payment by invoice to plans of capitative basis. The conclusions were that the payment model was not decisive in the variations and, instead, yes it was the "hospital” factor. I mean, what's really essential in potentially avoidable admissions is the supply of beds made available to the chronic patients.

Seventh thought

The most well-ordered systems (such as Kaiser or Mayo) are promising, but still they do not have all the answers

"The Dartmouth Atlas Project" evidences that the models that have evolved towards providing integrated services for chronic patients waste less and offer instead, a higher quality health care. For this reason, Wennberg believes that providers like Kaiser and Mayo, which offer integrated service for chronic patients are the ones to lead the way for others, although, he complains, these suppliers have not yet managed to stabilize their models enough and still have too many internal variations as to be replicable in other territories.

Eighth thought

It's not fair (part one)

It is not fair that people who live in areas where chronic patients go to the hospital less, should fund with their health plans and taxes the avoidable admissions of the territories that consume more.

Ninth thought

It's not fair (part two)

Wennberg says that patients who happen to live in areas where chronic patients are admitted more are penalized because they face more copayments (copayments that all the associations have, even Kaiser). This is a burden that these patients should not have to bear if their provider would offer integrated services and programs orientated to chronicity. And this is not fair for their savings and for their health.

Tenth thought

The improper use of hospital beds worsens the patients’ end of life experience

Wennberg argues that the unnecessarily tech death is a plague that should be fought with all our strength. And for this reason he brings on some statistics: 30% of chronic patients who die in Los Angeles die in an UCI or in a hospital bed after having gone through the UCI, while in the state of Minneapolis the same figure is 14%.

The demographic trends and budgetary pressures force us to confront the issue of waste of resources when caring for chronic patients. I therefore believe that we have no other choice but to apply Sutton’s law, which, if applied with professional judgment, is infinitely fairer than the usual transverse cuts.

Jordi Varela

No comments:

Post a Comment