Joann Kowalski: Let’s pay for health care quality instead of quantity

October 10, 2009

By JoAnn Kowalski

The United States ranks between 24th and 36th among the world's nations in qualitative measures of health care. Yet we're No. 1 in health care expenditures.

Why? Because our system of health care reimbursement is based on productivity rather than quality.

Without coordination of care, patients may visit several specialists, receive multiple medications that may not work well together, or ignore early warning signs until a crisis lands them in the emergency room.

In short, the health care system is not a system. It is an often haphazard, arbitrary consumption of health care resources that contributes to decreased quality of life, a shorter life expectancy and rising costs. Without coordinated case managing of patient appointments, treatments and prescriptions, the "system" becomes a liability, not a benefit.

Our current state of health is a direct result of a broken Medicare system. That "system" pays providers on a productivity and intensity basis. The more they see, treat or medicate the patient, the more providers are paid. And the more intense the services, the more they're paid.

If we give providers incentives to do more, more often, in more complex or intense ways, why would they change? We need to stop paying for quantity and start paying for quality.

Overlaying a benefit for the uninsured on top of a productivity-based system will only compound the problem. To make health care coverage possible for the uninsured, we must address this underlying conflict of interest.

Cost savings naturally flow from a model based on quality. HospiceCare provides an example. A quality-based system, HospiceCare is reimbursed a flat per-diem rate with clear expectations for numbers of visits based on the needs of the patient.

In 2008, HospiceCare served 2,652 patients. During this time, 130 emergency-room visits and 158 hospitalizations occurred. HospiceCare prepares patients and families for what to expect with the disease and its symptoms.

HospiceCare also becomes a patient's first call with rapid response nurses who provide in-home assessments to manage pain and symptoms. If the issues are unmanageable at home, the HospiceCare inpatient unit, a hospital or 24-hour crisis care are options.

Keeping 665 patients a day out of emergency rooms improves quality of life and saves Medicare and Medicaid money. Recent studies estimate each hospice patient saves Medicare about $2,300 by providing crisis care in homes.

Because this community has excellent health care providers who we partner with daily, HospiceCare has asked the Centers for Medicare & Medicaid Services to base a quantitative and qualitative demonstration study in Madison.

Specifically, HospiceCare has suggested that CMS analyze the 13 percent of HospiceCare patients discharged annually because they no longer meet the six-month-or-less prognosis required for hospice eligibility. Their conditions improve because HospiceCare's comprehensive case management involves limiting treatments and medications to just those that improve quality of life.

Lawmakers must focus on a fix for our current system by basing it on quality before even considering increasing coverage for the uninsured.

Kowalski is vice president of quality and compliance for HospiceCare Inc. in Madison; www.hospicecareinc.com.

As reported in the Wisconsin State Journal: http://host.madison.com/wsj/news/opinion/column/guest/article_30d46698-b5bb-11de-99b9-001cc4c03286.html