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The article's author Atul Gawande more recently published a study showing that you are 3 times more likely to die if you are treated in some hospitals compared

by MarkMc 9y ago

The article's author Atul Gawande more recently published a study showing that you are 3 times more likely to die if you are treated in some hospitals compared to others [1] Both the article and study suggest what I believe is a major failing in modern medicine: We should be measuring risk-adjusted outcomes for hospital treatments, then publishing a rating for each hospital on a bell curve. With such an approach, patients will naturally gravitate towards the better hospitals and the poorer hospitals will have an incentive to improve their procedures. Here's something to consider: According to the article, "In 1964... the median estimated age at death for patients in Matthews’s center was twenty-one years, seven times the age of patients treated elsewhere...After Warwick’s report came out, Matthews’s treatment quickly became the standard in this country." If Matthews's treatment had been less spectacular - say only twice the life expectancy of patients treated elsewhere - how much longer would it have taken for his treatment to become the standard? Perhaps never? [1] https://www.nytimes.com/2016/12/14/business/hospitals-death-rates-quality-vary-widely.html https://www.nytimes.com/2016/12/14/business/hospitals-death-...

SapphireSun 9y ago
I the interesting thing to consider is what happens to the hospitals that do terribly, but not so poorly that they should be shut down. The publication of their rating will start causing doctors and patients to avoid them. In our fee-for-service model, this causes the hospital to starve and enter a vicious feedback loop. Perhaps we should have an independent commission that has the ability to perform an outside investigation into these cases and attempt to understand what's going wrong. For hospitals that are under-resourced, they would have to power to increase allocations. On the flip side, it could shut down the ones that are irreparably broken that can safely be removed from a region. Also, we should do away with fee-for-service for good. It is the worst bag of incentives this side of the line between healing and hurting.
- JumpCrisscross 9y ago
  > In our fee-for-service model, this causes the hospital to starve and enter a vicious feedback loop Sounds like an alignment of interests between hospital management and patients.
  - SapphireSun 9y ago
    I don't understand how this helps hospital management once it enters the feedback loop. It does incentivize them to not get there in the first place, but I bet when you analyze the tradeoffs they make to forestall it you won't be happy either. This is especially a problem is when you have a lone hospital serving a poor area. The patients don't have money, maybe they don't have insurance. If the hospital starts cranking out bad results, it'll just deteriorate. The market model only kinda works in theory for wealthy populations with multiple hospitals nearby.
    - lmm 9y ago
      There's a market for cheaper, less safe cars. There would be a market for cheaper, less safe hospitals - in fact there already is, we're just embarrassed to talk about it openly.
      - SapphireSun 9y ago
        Think carefully about what you're saying. The rich get to live longer and healthier and the poor get substandard healthcare? The poor are the ones that need to work.
- epmaybe 9y ago
  what's the alternative to fee for service? At the end of the day, even if you abstract out these costs to bundled payments or other things that we saw in ACA, there's still a price attached to every service provided. Wouldn't that be the only way for the government to how much to budget for healthcare costs?
  - SapphireSun 9y ago
    The alternative is medicare for all bundled with something that looks like per capita allocations to take care of a patient population. Patients pay nothing at the point of service. Hospitals must drive down costs to make a profit. If they start cutting corners, they lose their bonuses. If they really aren't making enough money to do their job and can prove it to an independent board, their allocations can be increased. You can imagine some kind of bonus system based on YOY improvement or maintenance of patient outcomes.
    - nradov 9y ago
      That doesn't work for a single hospital in isolation since hospitals mostly only treat patients that present with serious problems. If you're going to use a capitation payment model then it has to cover a complete integrated delivery network including acute care, ambulatory care, laboratories, imaging, physical therapy, etc.
      - SapphireSun 9y ago
        That's what I was thinking of but didn't articulate correctly. Can you elaborate? What interactions fail if the model isn't comprehensive?
        nradov 9y ago
        There's just no practical way to do it. If a payer wanted to do capitation payments to a single isolated acute care hospital how would they even figure out what to pay and what incentive would the hospital have to take that deal? In order for something like an accountable care organisation (ACO) to work they have to control all aspects of patient care so that they have a chance to address problems early, long before the patient is admitted to the hospital.
countryqt30 9y ago
"3 times more likely to die" - what? The likelihood of dying is, for everyone, 100 %. So these people die with 300 % likelihood? #statistics
gambiting 9y ago
Well, there could be other factors too. When my dad was diagnosed with cancer, there was only one hospital in the country that had any experience in treating that specific type of cancer, so he had to go there, even though it was many hours of travel away from where he lived. If he couldn't do that, due to lack of money or resources to travel that far, he would have had to use a more local oncology department, but I can only guess that his survival chances would have been a lot lower, not because of any malicious factors, but because the doctors there had no experience treating that type of cancer and didn't have access to the latest treatments and funding for said treatments.

by MarkMc 9y ago

SapphireSun 9y ago

I the interesting thing to consider is what happens to the hospitals that do terribly, but not so poorly that they should be shut down. The publication of their rating will start causing doctors and patients to avoid them. In our fee-for-service model, this causes the hospital to starve and enter a vicious feedback loop. Perhaps we should have an independent commission that has the ability to perform an outside investigation into these cases and attempt to understand what's going wrong. For hospitals that are under-resourced, they would have to power to increase allocations. On the flip side, it could shut down the ones that are irreparably broken that can safely be removed from a region. Also, we should do away with fee-for-service for good. It is the worst bag of incentives this side of the line between healing and hurting.

JumpCrisscross 9y ago
> In our fee-for-service model, this causes the hospital to starve and enter a vicious feedback loop Sounds like an alignment of interests between hospital management and patients.
- SapphireSun 9y ago
  I don't understand how this helps hospital management once it enters the feedback loop. It does incentivize them to not get there in the first place, but I bet when you analyze the tradeoffs they make to forestall it you won't be happy either. This is especially a problem is when you have a lone hospital serving a poor area. The patients don't have money, maybe they don't have insurance. If the hospital starts cranking out bad results, it'll just deteriorate. The market model only kinda works in theory for wealthy populations with multiple hospitals nearby.
  - lmm 9y ago
    There's a market for cheaper, less safe cars. There would be a market for cheaper, less safe hospitals - in fact there already is, we're just embarrassed to talk about it openly.
    - SapphireSun 9y ago
      Think carefully about what you're saying. The rich get to live longer and healthier and the poor get substandard healthcare? The poor are the ones that need to work.
epmaybe 9y ago
what's the alternative to fee for service? At the end of the day, even if you abstract out these costs to bundled payments or other things that we saw in ACA, there's still a price attached to every service provided. Wouldn't that be the only way for the government to how much to budget for healthcare costs?
- SapphireSun 9y ago
  The alternative is medicare for all bundled with something that looks like per capita allocations to take care of a patient population. Patients pay nothing at the point of service. Hospitals must drive down costs to make a profit. If they start cutting corners, they lose their bonuses. If they really aren't making enough money to do their job and can prove it to an independent board, their allocations can be increased. You can imagine some kind of bonus system based on YOY improvement or maintenance of patient outcomes.
  - nradov 9y ago
    That doesn't work for a single hospital in isolation since hospitals mostly only treat patients that present with serious problems. If you're going to use a capitation payment model then it has to cover a complete integrated delivery network including acute care, ambulatory care, laboratories, imaging, physical therapy, etc.
    - SapphireSun 9y ago
      That's what I was thinking of but didn't articulate correctly. Can you elaborate? What interactions fail if the model isn't comprehensive?
      - nradov 9y ago
        There's just no practical way to do it. If a payer wanted to do capitation payments to a single isolated acute care hospital how would they even figure out what to pay and what incentive would the hospital have to take that deal? In order for something like an accountable care organisation (ACO) to work they have to control all aspects of patient care so that they have a chance to address problems early, long before the patient is admitted to the hospital.

countryqt30 9y ago

"3 times more likely to die" - what? The likelihood of dying is, for everyone, 100 %. So these people die with 300 % likelihood? #statistics

gambiting 9y ago

Well, there could be other factors too. When my dad was diagnosed with cancer, there was only one hospital in the country that had any experience in treating that specific type of cancer, so he had to go there, even though it was many hours of travel away from where he lived. If he couldn't do that, due to lack of money or resources to travel that far, he would have had to use a more local oncology department, but I can only guess that his survival chances would have been a lot lower, not because of any malicious factors, but because the doctors there had no experience treating that type of cancer and didn't have access to the latest treatments and funding for said treatments.