Blackjack: 21 ways to start driving down healthcare costs

[Roy Fokker, BSN, RN]

1. Remove failure to diagnose as a legal basis for a lawsuit.

To spend billions on testing "just to make sure" when your medical training says you already know the answer. The testing that is the result of that 0.5% chance you are wrong. No matter how much we try, we will never get it right 100% of the time. And that 0.5% unattainable goal is what drives much of the testing. As a society we need accept failure as a part of success. Some people may die, but many more will die as we bankrupt our system of care.

Unmanaged expectations are bankrupting our system.

2. Make futile care determinations legally binding.

Withdrawal of support in futile situations would not be a legal basis for a lawsuit. Refusal to escalate care could not be a basis for a lawsuit. If you want all care all the time, we will end up with no care, all the time.

Unmanaged expectations are bankrupting our system.

3. Super regional or national EMR system used by all players

If I can access a patients data base, I can get it right more often with less error and less testing. If the patient can update their own EMR data base of personal information, I can get it right more often with less error and less testing. If you have every primary care office, every specialist office, every hospital, every nursing home using EMR's that don't communicate, you have, in effect, a country of doctors who all speak different languages. Communication saves money

4. Establish a high speed medical Internet for digital imaging accessible by all players

Place the EMR on this high speed Internet. Along with it, place all digital imaging. If my patient had an MRI 1000 miles away on vacation, I want to know about it. If they had one last week at the outpatient radiology center in town, I want to know about it. Repeat testing happens because it's just easier than waiting for records. Doctors frequently only trust themselves or other doctors they know well. So a film is much more important than a verbal report of the film. We need to see the films ourselves or it will get repeated. Because trusting an unknown physicians

Communication is key.

5. Establish a national patient narcotic database for access by all physicians.

One of the most common medical complaints is pain. Pain is a symptom. A very subjective symptom. It is wrought with abuse potential. Combined with the fear of failure to diagnose, evaluating pain is expensive and is one of the most difficult jobs of all physicians. Knowing how much narcotic a patient is using and when and where they are filling it saves money.

6. Make inpatient treatment of alcohol or drug abuse mandatory for any qualified admission related to abuse or overdose.

If you are entitled to spend my tax money, I am entitled to see you in rehab, as many times as it takes. Drug abuse is expensive to the system in so many ways.

7. Fund chronic disease management interventions

In the current system, every aspect of care is fragmented. The primary care doc. The specialist, the pharmacy, the economics/social factors of care. Coordinating new models of disease care delivery will save money. Real time decisions with all players present makes decision making unified. A care plan visit . Not an office visit.

Our hospitalist group has daily am rounds with pharmacy and social work. We can save hundreds of thousands of dollars a year, in pharmacy costs alone. WIN-WIN. One hospital. One hospitalist group. Think of the savings. The reason docs don't talk? Everyone is too busy. Pay for coordinated care and you will be amazed at the results.

Communication saves money.

8. As far as hospital reimbursement goes, make all disease created equal

In the current system of diagnosis related group (DRG) a hospital is reimbursed the same (essentially) whether a patient is hospitalized for 2 days or two weeks for the primary diagnosis. Pneumonia? 2 days? Same payment as a 2 weeks stay. In other words money loser. Most primary care doctor admissions break even or lose money to the hospital. Not the case with procedural based admissions. Total knee arthroplasty? Cash cow. Unequal distribution of profit potential based on disease creates skewed market forces for competition. Surgical centers. Heart hospitals. This results in the creation of profit gradients within illness groups. Competition creates value and lowers costs. It should be spread equally in the hospital system.

I need hospitals competing for my pneumonia patient, not just the arthroplasty patients Once you have hospitals competing for my non surgical/procedural patients, you will have new found competition and cost savings that go with it.

9. Accept that all people are not created equal.

If you talk to 20 doctors you get 20 opinions. Who's right? They all are. There are many ways to get to the final conclusion. And the final conclusion may be different. 20 patients? You may have 20 different definitions of quality. Of outcomes. Of expectations. Of needs. A 40 year old with heart failure will have different expectations than an 87 year old with heart failure. And they will respond differently from interventions, medications. They will have different outcomes, defined by the patient.

That's 20 docs and 20 patients. 400 possible permutations of the process and the measured outcome. Finding that 1 out of 400 is The Art of Medicine. Accepting this premise accepts that all people are not created equal. Shackling the delivery of health care with undefinable goals and and expectations adds money to the system of health care delivery.

10. Quality should be defined by the patients pocket book, not government

In a market economy, patients decide what value they want. Cheap? Expensive? Value? The consumer decides how to spend their mighty dollar and they accept their value for their dollar. In medicine we are told what we can get. Every one is in the same hurried, fragmented, dis conjugated care. Why? Because Medicare says to doctors, if you accept this insurance, you have to accept it in full. You may not charge the patient more.

There are no rings of value. Unfortunately, not everyone is created equal, and there will always be variations in health and income. Rich and poor. Chronically healthy and chronically ill. The current system is all or nothing. Take Medicare in full, or leave it. The ability to find a middle ground and allow the patient to decide what they want to pay is present in every other service we as consumers can buy. But not our health care.

When you bring together happy doctors and happy patients good things happen. The current hurried, fragmented care model is expensive and adds to unnecessary referrals and testing. Allow the patient to decide what they want to pay for. What they value.

11. Make outcomes transparent.

Define them and present them. Let the patient decide what is important to them.

Click here to read the remaining 10 suggestions

Food for thought...

cheers,

[HM2VikingRN, RN]

most of these are congruent with recommendations made by the commonwealth fund....

one minor change to the above would be to take a lesson from the french playbook:

problem is, studies show that individuals are pretty bad at distinguishing necessary care from unnecessary care, and so they tend to cut down on mundane-but-important things like hypertension medicine, which leads to far costlier complications. moreover, many health problems don't lend themselves to bargain shopping. it's a little tricky to try to negotiate prices from an ambulance gurney.

a wiser approach is to seek to separate cost-effective care from unproven treatments, and align the financial incentives to encourage the former and discourage the latter. the french have addressed this by creating what amounts to a tiered system for treatment reimbursement. as jonathan cohn explains in his new book, sick:

in order to prevent cost sharing from penalizing people with serious medical problems -- the way health savings accounts threaten to do -- the [french] government limits every individual's out-of-pocket expenses. in addition, the government has identified thirty chronic conditions, such as diabetes and hypertension, for which there is usually no cost sharing, in order to make sure people don't skimp on preventive care that might head off future complications.

http://prospect.org/cs/articles?article=the_health_of_nations

[Elvish, BSN, DNP, RN, NP]

I like some of those suggestions, others I don't.

But at least he has been thinking and has offered some solutions instead of just griping about the problem(s).

[MBANurse]

woot...

someone gets it...

13. make patients responsible for more.

turn free=more into more=expensive. if you create cost structures to the patient that minimize their contribution, you will get entitled patients who expect everything for nothing. this is bankrupting our system. make the patient responsible for a greater portion of their costs. not everyone buys a lexus because not everyone can afford it. we live in a system where everyone wants the lexus, everyone is entitled to the lexus, whether they need it or not. if you want the lexus, you pay for a lexus.

19. take a stand on [color=#5588aa]emtala.

any patient who "comes to the emergency department" requesting "examination or treatment for a medical condition" must be provided with "an appropriate medical screening examination" to determine if he is suffering from an "emergency medical condition". if the patient does not have an "emergency medical condition", the statute imposes no further obligation on the hospital.

a screening exam does not constitute a full work up. emergencies are known at the time of presentation. but the basis for this overhaul must fall back on rule #1. you can't be sued for failure to diagnose. an emergency will be treated. non emergencies will not.

the emergency room has become an incredibly expensive way to practice exclusion medicine, not emergency medicine. after 10k worth of tests, the patient goes home knowing what they don't have, not what they have. the er is not the place to practice diagnostic medicine.

it is for emergencies. emtala has screwed up the whole system.

and i love this one!

6. make inpatient treatment of alcohol or drug abuse mandatory for any qualified admission related to abuse or overdose.

if you are entitled to spend my tax money, i am entitled to see you in rehab, as many times as it takes. drug abuse is expensive to the system in so many ways.

all of those ideas seem feasible and workable and not a one involves the government ruing healthing care for everyone.

[pickledpepperRN]

woot...

someone gets it...

13. Make patients responsible for more.

Turn FREE=MORE into MORE=expensive. If you create cost structures to the patient that minimize their contribution, you will get entitled patients who expect everything for nothing. This is bankrupting our system. Make the patient responsible for a greater portion of their costs. Not everyone buys a Lexus because not everyone can afford it. We live in a system where everyone wants the Lexus, everyone is entitled to the Lexus, whether they need it or not. If you want the Lexus, you pay for a Lexus.

19. Take a Stand on EMTALA.

Any patient who "comes to the emergency department" requesting "examination or treatment for a medical condition" must be provided with "an appropriate medical screening examination" to determine if he is suffering from an "emergency medical condition". If the patient does not have an "emergency medical condition", the statute imposes no further obligation on the hospital.

A screening exam does not constitute a full work up. Emergencies are known at the time of presentation. But the basis for this overhaul must fall back on rule #1. You can't be sued for failure to diagnose. An emergency will be treated. Non emergencies will not.

The emergency room has become an incredibly expensive way to practice exclusion medicine, not emergency medicine. After 10k worth of tests, the patient goes home knowing what they don't have, not what they have. The ER is not the place to practice diagnostic medicine.

It is for emergencies. EMTALA has screwed up the whole system.

AND I LOVE THIS ONE!

6. Make inpatient treatment of alcohol or drug abuse mandatory for any qualified admission related to abuse or overdose.

If you are entitled to spend my tax money, I am entitled to see you in rehab, as many times as it takes. Drug abuse is expensive to the system in so many ways.

All of those ideas seem feasible and workable and not a one involves the government ruing healthing care for everyone.

I agree with all of the above except the first.

If the other two were implementer it would go a long way toward solving the first.

Actually most people don't like to go to the doctor.

EMTALA does not require more than life saving emergency treatment.

At my hospital if the RN triage nurse, who has no other duties, has assessed you and you don't need to be assigned to a nurse you are sent home with instructions or accompanied to the urgent care across the street.

I do think that detox & rehab and mental health care should be mandatory. Too many patients are a threat to themselves. They also cause so many societal problems.

I floated to the ER. A young mother, who works at Starbucks (maybe because their workers get health insurance) brought her toddler by bus. Her finger had been closed into a door.

Mom was shaking and her teeth were chattering. The PA gave the baby lidocaine and soon that kid was laughing and playing "peek a boo". The ER doc mad an appointment for the baby to go right to childrens hospital across town.

I asked about a taxi voucher and was told, "No she can take the bus".

I paid for a cab. The Mom never asked. She was very meek and fighting back tears.

No Lexus , no old junk car either. Auto insurance is expensive too.

BUT life saving healthcare is NOT the same "choice" as a luxury car versus riding the bus.

[MBANurse]

I believe the first item listed (in my post) will have to be the first thing done in ANY system. People all to often feel that they are entitled to everything (because the government will support anyone and everyone) it is that sense of entitlement that needs to go away.

It was very heartwarming, the story of that little girl; and it was very kind of you to pay for a taxi... but what harm would have come from her taking a bus? There are all kinds of kids that are out there without alot of things. The government can not and should not provide for them all. That should be the parents.

[pickledpepperRN]

I am not the government. I never said the government owes anyone a Lexus. Has anyone?

The mother was almost in shock. She was sobbing, skaking, and her teeth were chattering. She had already taken several buses to take her baby to the ER with a finger hanging by a bit of tissue. The Mom had stopped the bleeding and got on the bus. She didn't call 911.

She had to take several more buses to take the baby to have surgery.

It can take hours to go a few miles in this city.

And she would have to fing the route with an injured baby.

I am NOT saying that her insurance that she gets through her job or taxpayers need to pay for a taxi. I am a mother too and tried to make an aweful day a bit easier for the Mom.

The point is what I said.

Life saving healthcare is NOT the same "choice" as a luxury car versus riding the bus.

[HM2VikingRN, RN]

I think what is missed in space story is that Mom could have called an ambulance. (which would have been far more expensive.) She didn't. She navigated the city bus system to bring her child to ER. I think she should have been given the voucher not because she acted entitled but because she was responsible in the first place.

[MBANurse]

I am not the government. I never said the government owes anyone a Lexus. Has anyone?

The mother was almost in shock. She was sobbing, skaking, and her teeth were chattering. She had already taken several buses to take her baby to the ER with a finger hanging by a bit of tissue. The Mom had stopped the bleeding and got on the bus. She didn't call 911.

She had to take several more buses to take the baby to have surgery.

It can take hours to go a few miles in this city.

And she would have to fing the route with an injured baby.

I am NOT saying that her insurance that she gets through her job or taxpayers need to pay for a taxi. I am a mother too and tried to make an aweful day a bit easier for the Mom.

The point is what I said.

Life saving healthcare is NOT the same "choice" as a luxury car versus riding the bus.

Where is an example of lifesaving healthcare?

[pickledpepperRN]

Mandatory treatment of debilitating substance abuse can be life savings. It will cost but will save in the long run. (A stitch in time saves nine.)

Funding chrinic disease management interventions and planning can save lives.

Why wait for the severe asthma attack, diabetic and HTN complications of CVA, MI, end stage renal disease, amputation and all when with planning and care people can live a productive life?

How about mammograms, colonoscopies, and such? With follow up if necessary?

...6. Make inpatient treatment of alcohol or drug abuse mandatory for any qualified admission related to abuse or overdose.

If you are entitled to spend my tax money, I am entitled to see you in rehab, as many times as it takes. Drug abuse is expensive to the system in so many ways.

7. Fund chronic disease management interventions

In the current system, every aspect of care is fragmented. The primary care doc. The specialist, the pharmacy, the economics/social factors of care. Coordinating new models of disease care delivery will save money. Real time decisions with all players present makes decision making unified. A care plan visit . Not an office visit....

http://thehappyhospitalist.blogspot.com/2007/12/my-black-jack-21.html

[azhiker96, BSN, RN]

Some of the suggestions are great and others not so good. At first blush the mandatory drug treatment sounds good but there's a problem with that suggestion. Rehab requires the patient to want the treatment in order for it to work. It's like a weight loss program. You can only control the behavior while they are in a controlled setting.

Great food for thought.

[HM2VikingRN, RN]

Here is another idea....

Make sure that there are urgent care services available from 0630 to 2200 M-F. 0630-1830 on weekends.