Reflections on the IHI National Forum (Part II): It's Not about the Money

*I should note that this post is less a reflection of any hard data that I saw at the IHI conference but more of a qualitative feeling that I got listening to workshops and some questions raised in my mind that were reinforced by later reading/reflection and a service trip that I took to learn about rural healthcare in South Dakota. It is also because of said service trip that it has taken me so long to write this article. So, I’m going to just try and post up the rest of my reflections from the conference today so I get them out before the new year!
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How often has the claim been made across the country that such and such an initiative that would improve the quality of care provide to patients was simply not possible because of the costs? That the incentives of the modern health care insurance system places far too much emphasis on the quantity of services provided and not the quality and so we will forever remain at the bottom half of all quality metrics among other developed nations?

Though not all of the changes some might like to see for aligning payment with quality are actually taking place, but there are a few real quality incentives on the way or already being implemented with the new healthcare reform. However, when I saw them being discussed at the Institute for Healthcare Improvement conference this year, I couldn’t help feeling that these “new” monetary incentives will continue to have a relatively minor role in improving quality. Whether they’re incentives to implement a new kind of technology (like the new health IT funds for implementing meaningful use electronic medical records) or even a new kind of healthcare delivery system (e.g. accountable care organizations), they will hardly ever raise the bottom line enough to justify the cost of implementation — unless quality is already considered part of that health care organization’s bottom line. As a recent NEJM editorial points out, though there is no association between better quality healthcare and higher costs, that also indicates that higher quality healthcare systems do not necessarily lead to lower costs.For the most part, the quality improvements commonly discussed — reducing hospital readmissions, improving provider efficiency — will not lead to lower bottom line but an increased capacity for the organization. Therefore, the actual cost savings for the organization (and at times the system as a whole) may be modest despite the upfront costs of implementing the changes in the organization and the changes in the quality of healthcare provided to the patients themselves.

So I would not be surprised that even if Medicare is providing some incentives to fulfill the hospital quality metrics, like being in the top 50 percentile in patient satisfaction, that many hospitals will not bother since their hospital is simply not configured to collect and quickly respond to patient input in a way that is really able to improve patient satisfaction.* Yet as I spoke to people working in regional healthcare systems during my service trip to South Dakota, I found hospital leaders that were taking their patients’ input seriously in redesigning whole floors of their hospital because it is supported by the new Medicare initiative and also because it’s “the right thing to do.” It’s common for us to gravitate towards some new change in the healthcare policy landscape as a reason for a change, but at hospitals like the one I was visiting, the infrastructural change that they implemented (complete remodeling of the patient floors to make a quieter, more comfortable hospital experience) had to have been planned long before the Medicare regulations were finalized and relied on a department of patient advocacy to collect and determine how to respond to patient input that had been in existence in that hospital, under various names and departments, for decades.

In other words, speaking further with the hospital leader who was giving the tour, that hospital had a long-established culture that supported efficiency and accountability in its staff. More strikingly, as a regional hospital in a mostly rural area, they are far from as well-resourced as some other places, with a predominantly governmentally-insured population (Medicaid/Medicare/Indian Health Services) and physically distant from many of the academic and cultural centers found in major cities that would draw the best of the best physicians. Yet, if I may idealize their example for a moment (not knowing other regional centers and with only very limited knowledge of even this one), they seemed to have a staff and leadership (including a community-elected board) that really seemed to care about serving their community as a whole, and so from the very beginning, the extent to which they were providing quality care to their community was already a consideration in their business planning before any financial incentives from Medicare were implemented to encourage such behavior.

Unlike financial incentives, culture is hard to quantify and even harder to disseminate. However, after my experiences of the past month, I can’t help feeling that it will be a far stronger driver for improving healthcare quality than all the financial reforms being passed down through the healthcare reform bill.**

  • Many may even go so far as to say that patient satisfaction is not a metric that should be focused upon since it is based on the arbitrariness of patient opinion rather than any patient knowledge of how good their care actually was (because what do patients know anyways?) I won’t dispute whether patient satisfaction is an objective or subjective measurement (subjective, clearly) but I would point out that focusing on patient satisfaction does first and foremost force the healthcare institution to listen to their patients’ commentary which is an important step in of itself.

** That is not to say that the financial incentives are not helpful or can be detrimental if not aligned with quality. Just that they are ultimately only a part of the story.