Curiosity, Dialogue, and Knowledge
It seems like every time you look away, a new Medicare rule is put into place. Seldom, it seems, are the rules designed to bring about better outcomes for patients. If there is any real method to the madness, then it’s as if an architect developed an elaborate blueprint detailing the structure of a cathedral only to find that once the building was made that it looked nothing like his design. While he was away, an accountant took out several expensive, but necessary features and kept ones that weren’t necessary. In the end you have a building that may look nice at first glance, but is bound to buckle under its own weight.
Medical care is expensive. It should be. It’s complicated.
In my opinion, all three of these statements are true. They are uncomfortable truths to say the least. The statement that many people will take umbrage with is the middle one- that medical care should be expensive. But, the facts are evident enough if we care to look at them: no other field requires as much training, no low-paying jobs require as much time and attention to detail, no other job delves so deeply into the physical and mental diseases that afflict us all, and finally both the quantity and quality of human lives are the stock in trade of medicine. In my mind, these facts help define why medical care is expensive, and why it should and will be in the future.
If medical care is understandably expensive (who, by the way, wants the Doctor with less education?), then who pays for it? In the current system, individuals that can afford insurance pay for it and Medicare pays for it, while the poor or unemployed or the those with pre-existing conditions wither, unless they are lucky enough to receive Medicaid benefits. The hidden costs creep in regardless. Those that wither eventually get care too. Like it or lump it. They just get care in the form of expensive ER visits for problems that could be prevented, problems that balloon into bigger more expensive problems. The cost of fixing a cavity ~$50; ER visit to deal with poor dental care ~$1000; math lessons for politicians ~ priceless.
We need to change our expectations. The reason why there are so many hoops for us to jump through is because of the above information. Costs are out of control, expectations are high, and instead of enacting meaningful change that benefits patients as well as reasonably dealing with budgetary concerns, we have steadily watched areas in healthcare that produce results get less and less funding.
One specific area to consider is inpatient rehabilitation facilities. Multiple studies demonstrate the effectiveness of the services we provide (see reference list below). But, the inpatient rehabilitation facilities have been under tightening scrutiny and capricious cutbacks ever since the prospective payment system was put into place in 2002. Now of course, there is a re-allocation of funds towards the nursing homes where less intense therapy gives the sickest ample time to recuperate, and the motivated a place to squander their motivation. Don’t get me wrong. I think the nursing homes should provide rehab, and they should be there to fill a distinctly less aggressive level of care for many patients that need it. To slowly move all patients that are too sick to go home toward this less potent form of rehabilitation, with a simultaneous shortening of acute hospital days, is not cost saving in the long run. It sets us up for continued problems. We will have patients that have short-term problems being taken care of in long-term care: wasting resources, time, and putting some very sick patients at risk because of less frequent doctor visits and fewer, less qualified nursing staff required. Returning to the original analogy, instead of keeping the cathedral design as planned, we have allowed the accountants to make changes crucial to the structural integrity of the design because it can save a quick buck.
At this point in our nation’s history, it’s anyone’s guess whether the newest laws will actually benefit patients more than the current system. In my opinion, we won’t know about the outcomes for that until they take full effect. If past history is any indicator of future performance … well let’s just say I have my concerns.
DeJong G, Tian W, Smout RJ, Horn SD, Putman K, Hsieh CH, Gassaway J, Smith P. Long-term outcomes of joint replacement rehabilitation patients discharged from skilled nursing and inpatient rehabilitation facilities. Arch Phys Med Rehabil. 2009 Aug;90(8):1306-16.
Anne Deutsch, PhD, RN, CRRN; Carl V. Granger, MD; Allen W. Heinemann, PhD, ABPP; Roger C. Fiedler, PhD; Gerben DeJong, PhD; Robert L. Kane, MD; Kenneth J. Ottenbacher, PhD, OTR; John P. Naughton, MD; Maurizio Trevisan, MD, MPH Poststroke Rehabilitation : Outcomes and Reimbursement of Inpatient Rehabilitation Facilities and Subacute Rehabilitation Programs. Stroke 2006, 37:1477-1482.
Gillen R, Tennen H, McKee T. The impact of the inpatient rehabilitation facility prospective payment system on stroke program outcomes. Am J Phys Med Rehabil. 2007 May;86(5):356-63.
Paddock SM, Escarce JJ, Hayden O, Buntin MB. Did the Medicare inpatient rehabilitation facility prospective payment system result in changes in relative patient severity and relative resource use? Med Care. 2007 Feb;45(2):123-30.