Sunday Forum: A health-care revolution

If you can get a warranty for a refrigerator, why not for bypass surgery? asks EUNICE LEE

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When we hear the word "warranty," we tend to think of washing machines, TVs and other manufactured consumer goods that come with a "no extra charge" guarantee if problems arise within a certain period of time. One of the last things we expect to come with warranties are health-care services, especially for procedures as risky as coronary artery bypass surgery. But the folks at Geisinger Health System, a hospital group in Central Pennsylvania, are defying expectations with their new "ProvenCare" program.


Eunice Lee is a student at Stanford University studying health policy (eunnah@stanford.edu).

The idea takes an important lesson from global manufacturing. When the goal is to create a consistently excellent product, it's important to improve each part of the production process to tamp down costs and ensure quality. It's time that health-care systems everywhere apply such exacting measures to the care they deliver.

Geisinger has overhauled its approach to elective heart bypass surgery in a dramatic effort to improve outcomes. Beginning in February 2006, Geisinger began charging a flat fee, promising no extra charges for any complications or hospital visits for 90 days after an operation. Previously, as is the usual practice, doctors and hospitals were paid for each additional service, regardless of the quality of their work.

The benefits of the Geisinger method are significant and proven. In 117 surgeries, death rates dropped to zero from 1.5 percent, readmissions dropped 15.5 percent and hospital charges dropped 5.2 percent. Geisinger clearly has overcome a major flaw in the current health-care payment system: When providers forget to prescribe an antibiotic or provide the wrong one or otherwise make a mistake, they are perversely rewarded by being able to bill patients again and again for any necessary follow-up visits.

"Geisinger is addressing an issue that has bothered many insurers and employers -- that when quality of care is less than ideal, the extra services often required by patients experiencing complications generate more revenue for the providers," says Paul B. Ginsburg, president of the Center for Studying Health System Change. For bypass surgery at Geisinger, the incentive is flipped: Doctors and hospitals are encouraged to provide consistently high-quality treatment and must take the financial loss if they don't. Wouldn't we like all of our doctors to have this kind of motivation?

If more insurance companies were willing to embrace Geisinger's approach, it would improve patient care and lower costs by reducing post-surgical complications.

Standardized care also is critical to Geisinger's approach. The health system had a panel of physicians identify 40 essential steps in bypass surgery. They then developed procedures to ensure that each step was followed by surgeons.

Geisinger is applying "evidence-based practices, and [making] sure they get hard-wired into the care process," according to Dr. Ronald Paulus, the health system's chief innovation and technology officer. Doctors may resist standardization, but it is invaluable to ensure that a consistent level of quality is maintained across hospitals.

In almost no other field would consumers tolerate the frequency of error that is common in medicine, said Dr. Donald M. Berwick, CEO of the Institute for Healthcare Improvement. Geisinger has managed to reduce the rate significantly.

An important issue that needs to be addressed when offering such warranties in health care is to make sure physicians do not preferentially treat patients who are less likely to suffer post-surgical complications. Since the costs of any post-surgical work within 90 days are completely absorbed by providers, they have an incentive to reduce them by means other than providing first-rate care. This problem could be addressed with regulations that prevent hospital administrators from choosing to treat certain patients over others.

It is vital that Geisinger expand such warranties and standardized procedures to show that the improvements they have demonstrated can be achieved in other types of care. It won't be easy, but that doesn't mean it shouldn't be tried.

The success of the Geisinger experiment testifies as to how dramatic changes can eradicate glaring flaws in the current system of health care. What is needed now is public support for the spread of this revolutionary approach to larger initiatives, such as Medicare. Recently, Medicare decided to end payments for common preventable errors in hospitals, indicating a growing belief that patients should not have to pay for others' mistakes. We all should make this belief explicit by sending letters to our members of Congress, asking them to support a broader warranty-based system.

The question is this: Should we continue to be victimized by a system of perverse incentives and unfair medical bills?

I hope that someday health-care quality assurance will live up to the standards of the fridge sitting in my kitchen.



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