Payment Reform and the Mission of Academic Medical Centers | Health Policy and Reform

by Paul F. Griner, M.D.

U.S. academic medical centers (AMCs) are facing new challenges to their financial well-being. As payers seek to control health care costs, teaching hospitals and their medical staffs can anticipate continued payment reductions. Under the fee-for-service system, hospitals respond to payment cuts by increasing their volumes of admissions and ambulatory services while improving efficiency. Although costs per case may decline, overall costs do not. The inevitable result is a further reduction in per-case payments, and the cycle continues — with many undesirable consequences. Costs are inflated, and the quality and safety of care are eroded as the result of unnecessary or inappropriate tests and procedures.

Rather than perpetuating this cycle, AMCs stand to gain by exploring payment reforms that promote evidence-based, rather than income-driven, care. Several such reforms are being proposed or tested, including payment per episode of illness, various forms of capitation, and an annual payment for the care of a defined population. Any of these approaches may include extra payments for meeting or exceeding quality standards. Commonly referred to as bundled payment, these approaches reflect the principle that health care providers should be reimbursed on the basis of the outcomes of care, not the inputs used to achieve them. Bundled-payment programs thus prioritize the discriminating use of health care resources, and the evidence shows that they can achieve cost savings while preserving hospitals’ revenues and physicians’ incomes. Despite concern that bundled payment may cause underutilization of services, experiments have shown that it does not have this effect. Some experts therefore predict that health care organizations will increasingly embrace bundled payments.
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Hit to the Wallet Corrects ADT Use for Prostate Cancer from MedPage Today

By Charles Bankhead , Staff Writer, MedPage Today

Medicare accomplished what clinical guidelines and evidence-based medicine couldn't: it reduced unnecessary use of androgen deprivation therapy (ADT) in prostate cancer.

Inappropriate use decreased by almost 30% from 2003 to 2005, following enactment of the Medicare Modernization Act, which lowered physician reimbursement for ADT. Appropriate use of ADT did not change during the same time period, according to an article in the Nov. 4 issue of the New England Journal of Medicine.

"Our findings suggest that reductions in reimbursement may influence the delivery of care in a potentially beneficial way, with even the modest [reimbursement] changes in 2004 associated with a substantial decrease in the use of inappropriate therapy," Vahakn B. Shahinian, MD, of the University of Michigan in Ann Arbor, and co-authors wrote in conclusion.
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Lessons from the Mammography Wars | Health Policy and Reform

by Kerianne H. Quanstrum, M.D., Rodney A. Hayward, M.D.

The controversy was predictable.

Since 2002, annual mammograms had been recommended for women 40 years of age or older.² Suddenly, an independent, government-funded panel was suggesting that this schedule might be too much — that less, in fact, might be better.

Advocates of breast-cancer screening, particularly breast radiologists, immediately took action, denouncing the panel’s statements as government rationing, suggesting that the panel members had ignored the medical evidence, and even implying that the panel members were guilty of a callous disregard for the life and well-being of women. As one prominent breast radiologist put it, “Basically, [the panel] said nothing is good. Just wait until it breaks through your skin. . . .”³ Specialty societies quickly issued countermanding guidelines.⁴

In reality, this independent panel, the Preventive Services Task Force, simply recommended that routine screening mammography begin at the age of 50 years, whereas women between the ages of 40 and 49 years should make individual decisions with their doctors as to whether their preferences and risk factors indicate screening at an earlier age. The panel also recommended that screening mammograms be performed every other year, which they suggested would reduce the harms of mammography by nearly half while maintaining most of the benefits provided by annual imaging.⁵ In short, the panel concluded that we had previously overestimated the value of mammography: that mammography is good, but not that good; that it is necessary for many women, but not all; and that it should be performed at some frequency, but perhaps not every year, for every woman.

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Medical News: Evidence-Based Treatment Improves Older Stroke Victims' Chances - in Cardiovascular, Strokes from MedPage Today

By Kristina Fiore, Staff Writer, MedPage Today

Older stroke patients remain at higher risk for adverse outcomes than younger ones, but the gap has narrowed with wider implementation of evidence-based guidelines, researchers say.

More than 10% of stroke patients over 80 died in the hospital, compared with 3% of those under age 50, Gregg C. Fonarow, MD, of the University of California Los Angeles, and colleagues reported online in Circulation.

But overall use of guideline-recommended therapies improved substantially in older patients from 2003 to 2009, particularly for patients over 90, they said.

During that time, several hospitals and stroke centers have adopted "Get with the Guidelines," an intervention to apply evidence-based guidelines to care. Adopters have seen "substantial improvements ... in performance measures for ischemic stroke patients, including pharmacological and nonpharmacological management in each age group," the researchers wrote.
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Medical News: Evidence-Based Treatment Improves Older Stroke Victims' Chances - in Cardiovascular, Strokes from MedPage Today

By Kristina Fiore, Staff Writer, MedPage Today

Older stroke patients remain at higher risk for adverse outcomes than younger ones, but the gap has narrowed with wider implementation of evidence-based guidelines, researchers say.

More than 10% of stroke patients over 80 died in the hospital, compared with 3% of those under age 50, Gregg C. Fonarow, MD, of the University of California Los Angeles, and colleagues reported online in Circulation.

But overall use of guideline-recommended therapies improved substantially in older patients from 2003 to 2009, particularly for patients over 90, they said.

During that time, several hospitals and stroke centers have adopted "Get with the Guidelines," an intervention to apply evidence-based guidelines to care. Adopters have seen "substantial improvements ... in performance measures for ischemic stroke patients, including pharmacological and nonpharmacological management in each age group," the researchers wrote.
Continue Reading