To Lower The Cost Of Health Care, Invest In Social Services
July 14, 2015
A repeated refrain of politicians is that health care spending in the United States is utterly out of control. We spend almost $9,000 per person per year, amounting to nearly 17 percent of Gross Domestic Product (GDP), far more than any other country, but get a poor return on investment. Life expectancy in the United States ranks 27th of the 34 industrialized nations that are members of the Organisation for Economic Co-operation and Development (OECD). Only three OECD nations have a higher infant mortality rate.
How is it that an abundance of advanced medical care can deliver such disappointing results? The answer lies in the fact that other developed nations do a far better job than the United States of preventing their vulnerable populations from suffering serious illness, by investing substantially more in social services that impact health. OECD nations on average spent about $2 on social services for every dollar of health care spending, compared to only about 55 cents per dollar in the United States, according to a study of 2009 data by Elizabeth Bradley of Yale University and Lauren Taylor of Harvard University. Factoring in these expenditures presents a new perspective: the United States is pushed down to 13th among OECD countries in total health care outlays.
The Basic Necessities Of Life
We need to think in broader terms about investment in health. While extensive batteries of tests and high-tech medical devices help us pinpoint illnesses and cure patients, low-tech social services also should be considered a key factor in our health care equation. The OECD data point to the fact that social services substantially improve population health outcomes while lowering spending on more expensive traditional medical care.
That’s because social services focus on the basic necessities of life, helping ensure that individuals receive adequate nutrition, proper shelter, and a subsistence income, all of which are essential to maintaining good health. When such fundamental needs are unmet, disease and illness often follow, and even after care is administered patients are highly vulnerable to relapse. Nearly one in five Medicare patients discharged from a hospital is readmitted within 30 days, resulting in an annual cost of more than $26 billion.
This is among the great cost drivers of medicine in the United States. Many of these patients, who may also be frequent visitors to the emergency department, face difficulty not just securing housing and food, but also maintaining proper hygiene, obtaining and properly taking needed medications, and regularly visiting a doctor. Such challenges can stem from a mix of underlying problems, including poverty, language barriers, and social isolation when there is no family member, friend, or caregiver who can offer assistance.
A Continuum Of Care
Enter the caseworker who ensures a patient has adequate heat in a home, makes sure an individual can purchase or receive healthy fruits and vegetables, and arranges support for the family caregiver whose health has severely deteriorated because she has ignored her own needs.
To achieve our goal of better health outcomes, especially for the needy, we must provide a continuum of care, integrating social services with medical treatment to ensure patients remain healthy. Outreach from a concerned caseworker dedicated to resolving non-medical problems can serve as a de facto first line of preventive care for at-risk individuals, and can be an effective strategy for lowering the cost of health care by proactively providing services beyond the walls of the hospital.
http://healthaffairs.org/blog/2015/07/14/to-lower-the-cost-of-health-care-invest-in-social-services/
Posted July 14, 2015, at 6:27 p.m.
In February 2012, LaVerne Stiles went to Citrus Memorial Hospital near her home in central Florida for what should have been a routine surgery.
The bubbly retired secretary had been in a minor car accident weeks earlier. She didn’t worry much about her sore neck until a scan detected a broken bone.
The operation she needed, a spinal fusion, is done tens of thousands of times a year without incident. Stiles, 71, had a choice of three specially trained surgeons at Citrus Memorial, which was rated among the top 100 nationally for spinal procedures.
It’s conventional wisdom that there are “good” and “bad” hospitals — and that selecting a good one can protect patients from the kinds of medical errors that injure or kill hundreds of thousands of Americans each year.
But a ProPublica analysis of Medicare data found that, when it comes to elective operations, it is much more important to pick the right surgeon.
ProPublica is making public the complication rates of nearly 17,000 surgeons nationwide. Patients will be able to weigh surgeons’ past performance as they make what can be a life-and-death decision. Doctors themselves can see where they stand relative to their peers.
See the death and complication rates for surgeons and hospitals near you by clicking here.
The numbers show that the stark differences that Stiles confronted at Citrus Memorial are commonplace across America. Yet many hospitals don’t track the complication rates of individual surgeons and use that data to force improvements. And neither does the government.
A small share of doctors, 11 percent, accounted for about 25 percent of the complications. Hundreds of surgeons across the country had rates double and triple the national average. Every day, surgeons with the highest complication rates in our analysis are performing operations in hospitals nationwide.
Subpar performers work even at academic medical centers considered among the nation’s best.
A surgeon with one of the nation’s highest complication rates for prostate removals in our analysis operates at Baltimore’s Johns Hopkins Hospital, a national powerhouse known for its research on patient safety. He alone had more complications than all 10 of his colleagues combined — though they performed nine times as many of the same procedures.
By contrast, some of the nation’s best results for knee replacements were turned in by a surgeon at a small-town clinic in Alabama who insists on personally handling even the most menial aspects of each patient’s surgery and follow-up care.
ProPublica compared the performance of surgeons by examining five years of Medicare records for eight common elective procedures, including knee and hip replacements, spinal fusions and prostate removals.
To be fair to surgeons, ProPublica’s analysis accounted for factors such as patients’ health and age. We focused only on elective cases because they typically involve healthier patients with the best odds of a smooth recovery.
As would be expected, overall complication rates were relatively low, ranging from 2 percent to 4 percent, depending on the type of surgery. But experts who reviewed ProPublica’s results say they strongly suggest that the typical surgeon’s rate can and should be significantly lower.
The evidence: Some 756 surgeons who each did at least 50 operations did not record a single complication in the five years covered by the analysis. Another 1,423 had only one.
The issue of patient safety has been at the forefront of American health care since 1999, when the Institute of Medicine released “To Err Is Human,” a landmark report on the startling frequency of medical errors.
But since then, medical errors haven’t abated — recent studies estimate that at least 200,000 patients a year die in hospitals from preventable errors and complications related to their care, which would make patient harm the nation’s third-leading cause of death.
Some say one answer is allowing patients to see surgeons’ track records.
“It’s long overdue,” said Dr. Charles Mick, former president of the North American Spine Society, who reviewed ProPublica’s findings. “Hopefully, it will be a step toward a culture where transparency and open discussion of mistakes, complications and errors will be the norm and not something that’s hidden.”
Many systems are supposed to protect patients from high-risk doctors. But ProPublica’s reporting shows that they often fail to identify problem performers.
The Centers for Medicare and Medicaid Services collects reams of data from hospitals and publishes hospital-wide quality measures. It recently started reporting some data on physician groups that voluntarily provide the information. The agency has plans to eventually publish quality data for individual doctors but it hasn’t done so.
CMS officials say focusing on doctors alone isn’t the answer because hospitals rely on teams of health professionals. Reducing patient harm “requires a focus on the full care team,” said the agency’s chief medical officer, Dr. Patrick Conway. “We believe this approach will help create a system that delivers better-quality care, spends our health care dollars in a smarter way and makes people healthier.”
The data for Toumbis, Stiles’ surgeon, shows that his Medicare patients suffered complications again and again between 2009 and 2013. Some 44 were readmitted to Citrus and another local hospital in the days and weeks after he operated on them, an average of nearly one per month.
Stiles was released the day after Toumbis operated on her neck. Minutes after arriving home, however, she collapsed. She died before the ambulance completed the short trip back to Citrus Memorial.
Toumbis had written in her medical records that the operation went well — no complications and no bleeding. But an autopsy by the local medical examiner found bone fragments, as well as almost two cups of pooled blood from an “extensive hemorrhage” in Stiles’ neck.
The examiner concluded that Stiles’ cause of death was a “complication of surgical procedure.”
Toumbis declined several requests for comment and did not respond to a detailed list of questions. Katie Myers, a spokeswoman for Citrus Memorial, said the hospital would have no comment on Toumbis.
“Our hearts go out to family members when a loved one passes away after surgery,” Myers said, “but sadly it sometimes does occur.”
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