It is July 1, 2017. A 67-year old man complaining of chest pain, shortness of breath and dizziness smartly calls 911 for an ambulance. The ambulance takes him to a nearby hospital. The medical staff examines the patient in the emergency room. They diagnose a heart attack (AMI – Acute Myocardial Infarction). They must quickly decide the best medical intervention to open up the blocked coronary artery that supplies blood to the man’s heart. It may be medicine. It could be inserting a cardiac catheter (PCI – Percutaneous Coronary Intervention) to open it up with a balloon and/or a place a stent to keep it open. They may decide on heart bypass (CABG – Coronary Artery Bypass Graft) surgery.
The man is in the hands of a great medical team and staff that will know which medical interventions he needs. PCI and CABG are proven medical interventions based on extensive scientific research and the perfected skills of Cardiothoracic surgeon led teams.
While the medical team is confident, the hospital staff is not so confident. They need to determine which interventions the man will need once he leaves the hospital. The man is obese, has COPD, diabetes and high blood pressure. They know very little about this man, yet they are now responsible for managing his care and medical cost for 90 days.
The hospital is located in one of the 98 metropolitan statistical areas (MSAs) that Medicare randomly selected for mandatory participation with Cardiac Bundled Payments. The hospital will be measured against a 90 day historical benchmark for the total cost of care for patient discharged after AMI, PCI or CABG. If the man ends up in any hospital emergency room for high blood sugar (Diabetes) on day 43 or is admitted to a hospital because he is struggling to breath (COPD) on day 82, the hospital is essentially on the hook for the cost.
The hospital had no role in selecting the patient or participating in Mandatory Medicare Cardiac Bundles. The hospital staff must consider non-medical interventions. These are interventions that are not reimbursed by Medicare or insurance companies, so it’s difficult for hospitals to pay for them. Choosing is difficult with little research on non-medical interventions as compared to medical interventions such as PCI and CABG.
The hospital staff may decide to install and pay for a $400 air conditioner prior to the man leaving the hospital on the 94 degree July 7th day. While the hospital will not get reimbursed for the $400, they essentially will not get reimbursed for the $5,000 Diabetes ER Visit on day 43 and the $13,500 COPD hospital stay on day 84. The hospital staff doesn’t have the benefit of hindsight, so how do they determine what works? Who gets the air conditioner? Who gets rides to cardiac rehab? Who gets a health coach? A study showed medication reconciliation delivered by pharmacists via home visits and telephone after hospital discharge was cost effective for select patients at $677 per patient. They must decide who needs what non-medical intervention, as they can’t afford to provide these services to everyone.
The US Healthcare system is designed to manage healthcare, not individual health. Medicare and commercial payers have been encouraging healthcare systems and physicians to manage health by promoting these new payments models. While healthcare systems and physicians are told they can pocket the savings, they often lack an effective managing health framework for alternative payments models such as bundled payments, Accountable Care Organizations (ACOs) and value-based payments. The research on which non-medical interventions work needs to be accelerated.
Medicare knows hospitals are not ready to manage individual health, so it plans delay the downside risk to hospitals until April 1, 2018 and phase it in over time. This still doesn’t give the hospitals in the 98 MSA’s much time to determine which non-medical interventions work. To effectively manage individual health, we need to understand the 80-90% of determinants of health that are not part of clinical care such as behavior, social, socioeconomic and environment. We also need to understand which non-medical interventions will work in addressing those determinants.