Back in the days when I was on the faculty of medicine, there was a rather pejorative phrase used to describe the practice of authors who would dole out results of a study piecemeal, in “slices” spread out over the largest practicable number of publications, thereby maximizing the number of CV entries per study. It was called “Salami Science.”
With Healthcare reform legislation now being described as “on life support,” many folks are wondering what, if anything is going to happen. Assuming “running for the hills” will not be an acceptable course of action for the Democrats, it is equally unlikely they will take what would be the politically disastrous step of enacting reform by “fiat” – either by passing the Senate version as it stands or by trying to pass portions through budgetary reconciliation requiring only 50 votes. Though the two Parties could theoretically try to arrange some sort of compromise legislation, (in fact, neither the House nor Senate versions is a “Bolshevik plot” designed to take over our government), this seems, in the end, unlikely.
This suggests the most likely outcome will be - law making “Salami Style.”
Under this approach, we will see individual aspects of reform taken up one at time in small chunks. It’s a slow and plodding style, and, predictably, the hardest aspects of reform will be addressed last, if at all. This style also pretty much ensures that when all is said and done the individual pieces won’t fit together very well. But as unappealing as this may seem, it appears to be the most likely outcome.
So for anyone trying to understand the likely course of legislation, it is worth reviewing the aspects of the plans that seem to have the greatest consensus, as these are the aspects likely to emerge relatively quickly into law.
Almost everyone can agree on the following broad categories:
· Paying and Reporting on Value – There is wide agreement on the following areas of moving toward paying for quality, not volume.
o Value based purchasing - Senate and House versions are very similar and may include, in addition to the evidence based care measures we have come to know well, an assessment of readmissions and hospital acquired conditions. The last two may also be attacked separately.
o Evidence based care – The emphasis on measuring adherence to evidence based standards is not going away.
o Transparency initiatives – The number of publically reported outcomes will grow.
· Testing Alternative Payment Models – especially those that span the continuum of care. The proposed piloting of several alternative payment methods is not controversial, and there is a growing consensus that we need to view care across the continuum, not in pieces. Expect to see some movement in this direction through pilots or CMS demos on the following:
o Bundled payments
o Medical home & primary care delivery
o Accountable Care Organizations
· Eliminating waste, fraud and abuse – Everyone can agree these have to go, and under the category of waste there is wide consensus that financial penalties can reduce each of these items and save CMS money at the same time:
o Hospital Acquired Conditions especially infections