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They've Got the Numbers On Us Now

June 3, 2009
by Mark Hagland
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One of the rarely challenged truisms in healthcare purchasing until recently has been the notion that “you get what you pay for.” For many years, provider executives and clinicians have argued that healthcare is simply a very expensive type of service to deliver, and that those who criticized high (and ever-rising) healthcare costs really didn’t know what they were talking about. And despite decades of data coming out of organizations such as the Dartmouth Atlas of Health Care and other sources, healthcare executives and clinicians have generally been able to hide behind what I’ve long called the “black box of clinical care.”

Well, those days are rapidly fading. A case in point: a research article that appeared in the May 21 issue of Health Affairs, entitled “Hospital Quality And Intensity Of Spending: Is There An Association?” by Laura Yasaitis, Elliott S. Fisher, Jonathan S. Skinner, and Amitabh Chandra. Yasaitis et al have done a major data crunch on hospital patient data, comparing spending on patients and the process measures related to the quality outcomes of those patients’ hospital stays.

Of course, there are a lot of details involved, but essentially what these healthcare researchers did was to take data from the Hospital Quality Alliance’s Hospital Compare data program (all available on its website), focusing on heart attack, pneumonia, and congestive heart failure outcomes, and compare that data with Medicare spending on those same patients. To be especially fair, the authors noted in their Health Affairs article that “We retained only those measures for which a majority of hospitals reported at least twenty-five observations in 2004, the first year for which data were available. This cut-off has been used in previous work to ensure sufficient statistical precision,” they explained. As a result, the researchers looked at process measures on which broad consensus exists regarding the efficacy of the processes involved, such as giving heart attack patients aspirin at arrival and at discharge and beta blockers at arrival and discharge, and providing the first dose of antibiotic within four hours of admission for pneumonia patients. Then, the researchers did a whole lot of careful sifting and categorizing of data in order to try to get as precise a set of results as possible.

The end result? “There was no association between performance on quality measures and spending for heart failure,” while the correlations between spending and overall quality scores was very weak for heart attack and pneumonia care. In other words, hospitals that expended larger chunks of care delivery on the Medicare patients studied (the researchers focused on end-of-life patients) did not necessarily correlate well at all with the use of the broadly agreed-upon care process measures that lead to good clinical outcomes.

The authors of this article concede that, after all the rigorous data-crunching they’ve done, more work remains to be done, using actual outcomes data (which these researchers did not do), and delving ever more deeply into the relationship between spending on care and the results of that spending. (And don’t doubt for a moment that more, and deeper and broader, data studies like this will be funded and published in the future.)

But the point is clear enough, I think: the time is over when providers can hide behind a screen of lack of data availability. Soon, very soon, I would argue, especially if value-based purchasing under Medicare is ratified by Congress later this year, we will get to the point where the level of transparency will make it impossible for hospital leaders to avoid the consequences of their organizations’ clinical outcomes.

The smart CEOs, CMOs, CNOs, CFOs, CIOs, and volunteer clinician leaders in the smarter hospital organizations are coming to realize sooner, rather than later, that it’s time to skate to where this hockey puck is sailing. Those organizations that can prove the value of their clinical care relative to its cost (and, let’s face it, relative to the cost of care in competing patient care organizations) will survive, and possibly thrive, in the emerging reimbursement environment. And that will require intensive data infrastructure work on the part of CIOs and their teams. Meanwhile, those organizations that aren’t able to justify their work are going to be increasingly challenged by public and private purchasers to survive, let alone thrive. Which type of organization will yours be?

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