I support Evidence-Based Medicine because the literature is growing exponentially and impossible to keep up with, especially for generalists. The critical thinking skills required of physicians (and others) to understand the studies and to prioritize their importance, are actually difficult to to develop and painstaking to practice. Even when I don't find myself interpreting the data the same as my colleagues, the framework is useful for understanding the controversies.
I support government regulation in health care because intervention is usually required to create a sustainable competitive market. This is basic tenet of capitalism and the belly-achers are usually the greatest mercantilists, reaping benefits out of proportion to their effort and then running away, with no concern for the well-being of the people and markets they have plundered. We are talking about the difference between profiting and profiteering.
It seems that government is always reacting to the margin of dishonest and profiteering players, to regulate in order to prevent abuse. However solutions are not well-thought out. By now, I hope the reader realizes I am talking about the CMS decision not to pay for complications.
How can anybody object to that! I mean, who wants complications! We want free care and the people paying the providers... they shouldn't pay for anything if we don't do well. The landscape is that complaining about the rules is such that everyone who objects sounds like a strident, little school child throwing a schoolyard tantrum.
The contradictions are painful: hospitals and physicians are required to adhere to the best evidence, but government can act with no evidence. What's is wrong with the CMS decision? Ahh, let me count the ways...
- The intervention here is provide a financial incentive to spur the adoption of actionable quality data gathering that results in an improvement in outcomes.
- Any intervention must be based on the reasonable expectation of getting the effect you want. Being punitive, the chain of incentive--> data --> hospital system change --> improved outcome is abrogated at step one.
- There are alternatives to complete non-payment for a complication; how about a 50% reduction associated with a 25% end-year supplemental reward for the 100 hospitals showing the best results, or the most improvement. Small steps
- A disincentive (non-payment) is not the same things as an incentive.
- Budget constraints provide clear motivation for calling non-rational thought processes evidence based.
I am now more convinced than ever that policy is driven by money, politics and power, but I would have hoped someone would at least pay lip service to the science.
NB: I am not a hospital administrator and having nothing to gain or lose from the new set of regulations.
2 comments:
I find myself in agreement with each and every one of your points.
Well-argued! I fear it is the poor, elderly and those with already-limited access to care who will suffer the most, when hospitals close due to this latest assault.
Why not just mandate the proven practices to which Dr. Leape alludes to (yet does not list) in his editorial? I am appalled also at his writing; was he not a big proponent of the "systems" thinking behind causation of errors, as opposed to pointing a finger of accusation? Didn't he used to speak against the punitive approach to managing errors?
He seems to think hospitals and their staff and administrators have just been sitting around peeling grapes for drinking mimosas.
In any case, this CMS reg will just inspire a new round of careful deception at hospitals--I bet the rates of some events suddenly plummet, not because better care will be given but rather because hospitals will find a way to code the events differently or not at all. And I don't blame them! But who has won then--I doubt that hospital care will have improved; in fact, it may have deteriorated as hospitals will have to divert resources to manage this new risk of non-payment.
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