Friday, April 10, 2009

Gainsharing: Who Gains?

Business people love policies that are "win-win."

And with health care occupying an increasingly important portion of our gross national product, medicine has become big business. So it makes sense that the "stakeholders" in medicine like a good "win-win" scenario, too.

Do a better job, and the patient gets better. "Win-win." Work more efficiently and use less resources so costs are dropped. "Win-win." Do a really good job, meet some quality targets that an insurer has set for a hospital, then maybe the hospital can pass on those bonuses to doctors. Hey, it's a trifecta! "Win-win-win!"

It sounds so good on paper and in theory. In fact, it sounds so good, that even the Office of the Inspector General (OIG) of the United States seems to be warming up to the idea of more gainsharing arrangements.

And gainsharing offers limitless opportunities for marketing to our new health care "consumers." (I think that means "patients," but I'm not always sure.)

Perhaps the best example of the juicy marketing spin regarding gainsharing can be seen at the Geisinger Health System that guarantees coronary bypass outcomes:
"Mimicking the appliance company that advertised its products’ reliability, the health system devised a 90-day warranty on elective heart surgery, promising to get it right the first time, for a flat fee. If complications arise or the patient returns to the hospital, Geisinger bears the additional cost."
Simply brilliant. Who wouldn't want that, right?


But there's more:
"The venture has paid off. Heart patients have fared measurably better, and the health system has cut its bypass surgery costs by 15 percent. Today, Geisinger has extended the program to half a dozen other procedures, and initiatives such as the counter-intuitive experiment in Pennsylvania coal country are now at the heart of efforts in Washington to refashion how care is delivered across the United States."
See? Utopia. Right here in the good 'ol U.S.A.

All on the backs of "gainsharing."

That's right - when they do everything by the book in their "Proven-Care" program, Geisinger achieved (according to the above article) a 0% 30-day post-bypass mortality using their "Proven-Care" methods! Unbelievable!

To which, I say, they must not be treating very sick patients.

I used to have a senior attending who told me that you never want to be cared for by a doctor who had never seen a complication. Complications are why fellows spend so many hours in a catheterization laboratory. They happen. Even in the best of hands. And it's the process of dealing with those complications where fellows do their advanced learning. That's where they learn to deal with the unexpected, the complicated, the unusual, and yes, the sick. As one attending said, "Any moron can sink a Jud." ("Jud" in this case referred to a JL-4, "Judkins-Left-4cm" standard left heart diagnostic catheter that usually finds the left main coronary orifice easily). The implication of his statement was that's is not about doing the easy, routine stuff that really helps the patient (anyone can do that), it's the hard stuff - the stuff that's not automatic, not in the textbook, or not in the algorithm - that shapes us as physicians.

Certainly, there is good that can come from developing an organized, team-approach to health care. When everyone is involved at improving the system, patients benefit (can you say "TQM - Total Quality Management?"). But when that effort is tied financially to outcome incentives, the risk of gaming the system to assure better outcomes can be expected. After all, business ethics are not medical ethics.

As a case in point, when we see perfect mortality scores as a result of "gainsharing" arrangements we must ask ourselves, what has been sacrificed in the name of outcome perfection? Which patients were excluded? Will only insured patients have an opportunity to participate in such a program because they are effectively "pre-screened?" Where are the sickest being shunted? What kind of health care system are we striving for - one that treats the "kinda sick" but not the "real sick?" Do we really want to reward perfect mortality scores at the expense of ignoring the benefits that occur to our patients from calculated risk-taking, even some outcomes may be less than perfect?

Who gains then?


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