Unexpected Effects

Read a fascinating article in the N.Y.Times today, Perfect Vision Is Helping and Hurting Navy -- seems the Navy is providing laser eye surgery for about a third of all Naval Academy midshipmen. Sounds like a pretty good deal -- now sailors who previously were restricted in their career choices by virtue of bad vision have new options for becoming fighter pilots, special forces, things like that.

Not so fast -- there's a catch. Now apparently there aren't enough submarine officers in the Navy:

For generations, Academy graduates with high grades and bad eyes were funneled into the submarine service. But in the five years since the Naval Academy began offering free eye surgery to all midshipmen, it has missed its annual quota for supplying the Navy with submarine officers every year.

Officers involved say the failure to meet the quota is due to many factors, including the perception that submarines no longer play as vital a national security role as they once did. But the availability of eye surgery to any midshipman who wants it is also routinely cited.

Imagine that. Sailors are getting the chance to do something they want to do. That's certainly an unexpected effect of the treatment process.

Fast forward a few years. The general population is ageing. Life-extending medical and surgical treatments are improving. "Augmented health" procedures are improving as well. More people are going to be healthier longer, are going to have healthier children, are going to spawn longer-living, healthier interim generations. Is that an unexpected effect too?

Careful with your healthcare, there...

Yesterday, I was thinking about the tricky state of healthcare economics and incentives, from the point of view of payers and providers. The issue was that Blue Cross of CA is giving doctors incentives to use ambulatory care resources (endoscopy centers instead of hospitals) to ease the cost of patient care. The California Hospital Association fired back with a lawsuit claiming that such incentives violate the provision that financial concerns should not cloud doctors' vision or response to critical patient care.

Today I read about another progressive "solution" to the challenge of delivering high-quality, cost-effective healthcare to consumers -- a news report that McKesson Acquires RelayHealth. Listen to this:

McKesson also announced a new Personal Health Solutions group within its Provider Technologies segment. Personal Health Solutions will serve the growing market for interactive technologies that empower consumers and patients through secure electronic access to healthcare providers, personal health records, healthcare financial management systems and other tools. The group will leverage McKesson's broad-based strengths in disease management services across the entire continuum of care, from hospitals and outpatient facilities to physician offices and into the home. In addition to RelayHealth, McKesson's personal health solutions include in-home patient monitoring, Web portal technology, triage software and personal emergency response systems, to name a few.

Now, here's the conundrum:

If my insurance carrier offers me and my caregivers incentives to use new technologies, such as patient-physician portals for online, interactive visits and treatment, is there a chance some hospital association is going to sue me for threatening my own well-being?

I think The Healthcare Mess is a mess because we really don't understand incentives well enough among payers, providers, and consumers.

Or, then again, maybe we understand them all too well...

Have it both ways...

Read two interesting articles last week about "the health care mess." Actually, they purported to be about different subjects, but I relate them both to The Mess.

First was "Payers can drive healthcare transformation with IT help", a report on consumer-directed healthcare -- or, more to the point, what payer organizations have to say about, and have to gain from, use of sophisticated IT technologies to make delivery of service more beneficial to the consumer. To the patient. For example,

Health plans have been piloting incentive programs, including pay-for-performance, practice rewards and employer waivers for drugs for employees in disease management programs, and seeing significant uptake...[It was] stressed that the fundamental strategy for appealing to providers and consumers is to get the information into the hands of providers and democratizing information and getting it to consumers.

Second was another innocuous little report on incentives, "California Hospital Association sues Blue Cross on payment policy." This too purported to place the interests of the consumer -- of the patient -- in the forefront. Here's the issue in this case:

The California Hospital Association is suing Blue Cross of California, claiming a new policy by the health insurer will violate state laws because it would pay doctors who opt to perform endoscopies in hospitals less than those who do so in less expensive outpatient centers... "(Doctors) are supposed to make decisions unhindered by financial considerations," [the CHA
spokesperson] said. "They're supposed to make them solely on the medical well-being of the patient."

Who, I wondered when I read the two articles together, and reflected on the positioning that I must imagine is constant among payer, provider, and patient-advocate organizations, has the best interests of the consumer at heart? Of the patient? The CHA action centered on (or orbited around) endoscopies; but you can bet this argument is gonna heat up once we start looking into more involved procedures. The incentives posed by the Blues, as I understand it, would encourage use of distributed endoscopic facilities outside of hospitals to handle an increasing flow of subjects (consumers, patients) for the procedure. The hospitals, it seems, cried foul, claiming a disregard for issues of patient safety and treatment quality on the part of payers who were compromising docs by "forcing" them into financial rather than medical considerations for treatment.

I was considering both sides with impartial interest -- until I read in the second reference the rebuttal from a WellPoint spokesperson (parent of the Blues):

Alaniz said the payment policy is merely an incentive for doctors to do the procedures in such centers. Endoscopies can cost between $300 and $500 in ambulatory surgery centers, compared to between $2,100 to $6,000 in hospitals, he said.

So, I wondered -- if I were an advocate of an organization that has established, high-quality processes for critical treatments, and I were threatened by delivery of same services at 1/4 to 1/7 the cost (!!), just what would I do?? Then I wondered, if I were and advocate of a consumer-oriented organization that constantly seeks the best established, high-quality processes for critical treatments -- you know: if I were a patient -- then what would I do??

Gee, I wish I could just have it both ways.