Spinning your wheels...

http://online.wsj.com/article/SB10001424052748703961204575280903681581516.html

The above link will take you to a Wall Street Journal article which reports an article that will come out next week in the Journal of the American Medical Association (JAMA).In short, it has been ascertained that although the length of stay (inpatient) has been reduced by about 25%, the cost of caring for Congestive Heart Failure CHF) has risen because of increasing rates of readmission to the hospital within 30 days of discharge. This is an extremely important article which will probably fly well below the radar.

It is important because the chief cause of medical cost inflation has been, is, and will continue to be driven chiefly by the management of chronic diseases. The king of chronic diseases is CHF; as goes CHF, so goes the Medical Economy. A list of the top ten chronic disease states consumes a disproportionate share of medical dollars. To reel in run-away inflation in health care, the efficient management of chronic diseases must be conquered. Unfortunately, we appear to be heading in the opposite direction. The failure of shorter hospital stays to reel in costs must serve as a barometer signalling a larger approaching storm.

Here is my take on the problem. There has been a new paradigm at work for some time now; there has been an increasing fragmentation of care into ever smaller discreet units--a deconstruction of care if you will. The old paradigm was fairly simple. When a patient showed up in the ER with decompensated CHF, the attending physician would go to the ER, admit the patient, care for the patient in-house and then discharge the patient back to his/her office for follow up. Under the new paradigm, the patient is evaluated by an ER physician (and more often by a PA or Nurse Practitioner). The ER mostly has to make the binary decision to admit or not admit. If admitted, the CHF is then monitored in-house by a team of hospitalists who bring the CHF back under control. The patient is then discharged back to the primary care physician who may not even know that his patient was in the hospital.

In each case let us assume that the transfer of information is 90%. Under the old system, the efficiency is 90% because the physician is involved (and running) the entire process. Under the new sysytem, there are at least three transfers which leads to an efficiency of transfer of information of (.90 x .90 x ,90) or about 72%.

Assigning an arbirary rate of 90% is pretty generous; if we assume 60%, the new overall rate becomes (.60 x .60 x .60) or roughly 21% overall. Recall the game that you played as a child where you sat in a ring with 6 or so friends and whispered a sentence from one to the next until back at its origin. Hence, "The blue horse stood next to the red fence." becomes "The red horse is glued to the red barn." You get the idea.

Many providers actually embrace this new paradigm of fragmentation. Once the case is passed on to the next provider, there is no responsibility for, nor vested interest in, the future of the case. In addition, billing is maximized. Just as procedures are much more lucrative than cognitive services, providers have found that LIMITED discreet interactions with patients are more lucrative than long term relationships. Congress manufactured this system with their stupid reimbursement schemes and price controls which foster the fragmentation of care into ever smaller parcels--each with its own discreet billing codes.

The fragmentation noted above is external as it occurs between distinct groups. There also exists internal fragmentation where the care is divided up within a group. Is the hospitalist who admits you the same hospitalist who discharges you and passes on the history of the stay? Increasingly, large medical groups are employing PA's and Nurse Practitioners who "share" the management of cases with ever increasingly distant physician supervision. Of course, as an internist who managed my own patients with CHF, I have some bias against the new system...however, this landmark article seems to show that this new fragmented system is not working so well. There is a lot to be said for knowing your patients inside out. Protocols and check lists, although useful, are no substitute for knowing the patient--nuance is important.

In some respects, this fragmentation resembles the securitization of mortgages which almost brought down the country 18 months ago. That process was fragmented as well with no one taking overall responsibility. The originator passed off to the broker who passed off to the banker who passed off to the securitizor who passed off to the investor. At each step, some value was stripped out and all responsibility was passed on down the line. Keep the assembly line going. Look how that ended.

The mantra of the 1990's was "faster, better, cheaper". In physics, Heisenberg's Uncertainty Principle suggested that we can know the position and the momentum of a particle but we cannot know both at the same time. It appears that we can have faster, better and cheaper but we cannot have all 3 at the same time.

James Carville, running Bill Clinton's Presidential campaign famously said "It's the economy, stupid." In the instant case, we should be saying: "It's the continuity, stupid." This JAMA article is very important in terms of hinting where the management of chronic diseases needs to head. Whether or not we have the political will to make the necessary course correction is not at all clear.