Sunday, August 30, 2009

Why we need health care reform

Fee-for-service penalizes evidence-based care. Check out this story, highlighting evidence-based practices at Utah hospitals and discussing the success of one hospital system's restrictions on early induction:

[D]octors and nurses resisted the new guidelines. From their vantage point, it was hard to see a problematic pattern, according to an Intermountain study published in the journal Obstetrics & Gynecology in April.

This made sense, considering that if an obstetrician performs 200 deliveries a year -- and 10 percent of his or her patients are electively delivered at 38 weeks -- statistics show only one baby would be admitted to the neonatal intensive care unit (NICU) each year.

When Intermountain analyzed nearly 180,000 births, however, the data were startlingly clear: For babies born at 37 weeks, the incidence of severe respiratory-distress syndrome was 22.5 times higher than those born at 39 to 41 weeks. At 38 weeks, it was still 7.5 times higher. Other problems, such as pulmonary hypertension, admission to the NICU and hospital stays beyond five days, were also more likely.

"If no one ever gives you the scientific data to drive your decisions, you can be pretty comfortable not doing best practice. You just don't know," said Janie Wilson, operations director of Women and Newborn Clinical Programs, which in 2001 developed a program to curtail early-term deliveries. ...

Within six months of the initiative... the rate of early-elective deliveries at Intermountain hospitals dropped to 10 percent from 28 percent; eight years later, that number is less than 3 percent.

But something else happened, too: Intermountain lost money. By performing fewer early-term elective deliveries, the health system saw shorter lengths of stay. NICU admissions dropped. Patients received fewer lab tests, antibiotics and Caesarean-section surgeries.

"The bottom line to our cost was significant," Wilson said.

An analysis of the impact on the health system revealed it lost $3.3 million in net revenue between 2001 and 2005. And that was a conservative estimate, based only on length of stay in labor and delivery, Wilson said.

To have a profit-driven system, you don't have to have individual providers rubbing their hands together, cackling gleefully over all the extra money they're going to make with early elective inductions. Everyone can intend the best for mothers and babies, but the incentives just aren't there to take a closer look at the evidence. And when the evidence comes up on the side of fewer reimbursements, that's one less argument you can use to make your case. Health care reform that rewards evidence-based care and de-emphasizes fee-for-service can change that.

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