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Healthcare Reform "Salami Style"

January 31, 2010
by richard
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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 Readmissions

o Hospital Acquired Conditions especially infections

Strategically minded CMOs and CIOs should think through how their systems are going to support the data and information needed to drive efficient and effective care across the continuum as well as how their systems are going to help identify and eliminate readmissions and HAC including infections, which are currently in the crosshairs and are likely to be for some time. The emerging legislation will ensure that there is more to meaningful IT use in the future than is contained in “meaningful use.” No, Healthcare Reform is not dead; it’s simply being moved over to a deli counter near you. The likely menu choices have implications for your institution and its IT strategy.


This is a fantastic summary, Dr. Bankowitz, thank you! And I agree with your analysisI think that value-based purchasing, evidence-based care, alternative payment models, and the evergreen elimination of waste, fraud and abuse, will all be at the top of the list in terms of areas with strong bipartisan support going forward. Thank you again for this very incisive post.


Two very timely questions.

One thing I would note, is that paying for value, rather than pure volume, is, in fact payment reform. But I think your question is a broader one along the lines of "will this work in the absence of fundemental payment reform in which we stop paying by the procedure or by the stitch and start paying for health?" I don't agree that quality and safety can not improve in the absence of a payment overhaul. Would we see a greater cange if we payed for health rather than illness - yes. But in my experience, simple transparency of outcomes goes a long way to motivate change. No one likes to be on the bottom of the list and a little peer competition goes a long way. So simply measuring and reporting outcomes is helpful in improving quality, and of course tying part of payment to the outcomes will help. Some have said the payments in the CMS / Premier HQID demo were insufficient to motivate change. I think this misses an important point. The payment incentives did one very important thing: They got the CMO and the CFO talking to each other and aiming towards a common goal. The impact of this should not be underestimated.

With regard to waste, I think the Thompson Reuter's paper did a nice job of summarizing the literature. Perhaps less of a true study than a review, it nonetheless lays out the scope of the issue. A large part of Premier's activites involve helping hospitals to eliminate waste and we are presently trying to catalouge its various components. Perhaps I can make this the subject of a future post.

Thanks for the questions.

I agree with Mark that you laid out a very thoughtful scenario that is pragmatic for health system planners.

Given your experience with CareScience, your prior experience contributing to the work of AHCPR, and your current work with Premier, do you share David Goldhill's concerns that the "Paying and Reporting on Value" (not a new idea) in the absence of significant payment reform will be unlikely to impact quality and costs? Said differently, does the Premier CMS P4P demonstration project that showed improved quality and costs likely scale up in a positive way, as a result of the ARRA/HITECH stimulus?

In a related question, what is your or Premier's perspective on the Thompson Reuter's study on waste, described here.  We (HealthTechNet of Washington) had the primary author present and discuss his findings in January.  During that discussion, the challenges of inference to the general population where discussed.  With similar issues to your Salami framework, we concluded that "more studies are necessary!"

Mark, Thanks for your comments. Yes, these items on the top of the list are likely to get taken up at some point and they are unlikely to go away given the support they have received.

I understand your realism and I agree with your observation about politics. Aside from the profitability or costs to each of the stakeholders associated with unvarnished EBM, there's another, related high level factor.

In my blog post from Thursday, July 23, 2009, "
Obama Asks Bloggers For Help With Health Care System Overhaul -
Show me the quadrants," I shared a 2x2 table. The top, left hand quadrant was those EBM initiatives that both save money and increase quality. Colonoscopy for people over 50 years old is a commonly cited example. EBM for care that increases costs, either early or late will have powerful opponents.

There has historically been some real pseudo-science associated with some EBM. The data and/or it's interpretation has gone outside of good science.

Politics doesn't always align with Safety, Patient-centeredness, Equity, Timeliness, and other noble goals articulated by the IOM (STEEEP).

Ah...EBM...evidenced based medicine. Or should it be EBM-IPP?
The IPP is - only If Politically Popular. What I recently saw with EBM for mammography and Pap smear screening was, if the eveidence had a stong lobby with big bucks behind it then we ignore the evidence and attack the researcher. Value be dammed!

I hate to say it, but the only real evidence I see is that we as a society will not, and cannot, accept 'the evidence' if our ox is to be gored. The same goes for eliminating waste, with a strong lobby your waste is my meal.