Not all patients are the same. If they were, the machine would have already replaced the doctor. Physicians were drawn to medicine for the art of caring for the patient. The details, the nuances and the subtleties of the person as a whole, from the story to the exam to the anatomy, add a level of clinical complexity that keeps the physician both humble and curious.
As medicine continues to be strong-armed into the world of big business driven by the bottom line and patient satisfaction, growing pains emerge in how we are forced to address patient differences. In the search for cost conscientiousness and improved population health, it is a difficult but important realization that not all patients require the same quantity of resources to reach the desired goal of care.
While there are many factors that contribute to a successful treatment or surgery, time and time again the evidence-based literature demonstrates some of the most important factors are the patient’s preexisting medical conditions and social factors.
As cogently detailed by Dhruv Khullar, we have failed to acknowledge and confront how inherent patient differences should be built into our present day care model. For those who require more resources, the cost of care will be higher.
Continuing to ignore the complexity physicians were trained to embrace perpetuates a system in which the health disparity gap widens.
Today, “value” has become a colossal buzzword in medicine. Originally introduced to curtail the practice of arbitrary and uncontrolled costs, value-based care is classically characterized as the ratio of outcomes to cost, although this fails to answer "value for whom?" and even the experts disagree on how to define outcomes or cost. What exactly is the ideal outcome for a given patient?
The recent emphasis on shared decision-making and expectation management promote counseling on a case-by-case basis, as we acknowledge patients should not be bundled into a “one size fits all” approach. Cost is even murkier. How much does a pill or surgery truly cost the patient, the hospital or the insurance company? Where is the transparency?
Nonetheless, the recent infusion of value-based care has addressed many issues but unroofed others.
Total hip and knee replacements represent some of the most commonly performed procedures and are thus the most commonly reimbursed procedures by Medicare, making these procedures an ideal place to start when implementing a new payment model.
The CMS introduced the Comprehensive Care for Joint Replacement program, which treats patients one and the same by allowing Medicare to pay hospitals a fixed fee for an entire episode of care up to 90 days after a hip or knee replacement.
There has been marked early success with aligning interdisciplinary care teams and establishing systemic efficiencies.
However, this fixed “bundled” payment model commoditizes patient care by failing to account for anatomic complexity, medical considerations, or social factors.
With a fixed fee for all patients, health insurance payers tacitly transfer the onus to hospitals that potentially incentivize surgeons to “cherry pick” healthier patients whereas those who may require more perioperative care or present unique technical challenges are potentially “lemon dropped.”
For these denied patients, they are forced to visit large referral centers that may be located hundreds of miles from home. The present system of bundling patients as if each and every individual were the same is not only inaccurate but also promotes patient selection, presents ethical dilemmas and exacerbates health access issues specifically for patients who need care the most.
The notion of health equality with a bundled payment model is an intermediate improvement that has decreased preventable costs.
However, if patient-specific issues continue to be ignored, this fixed fee model may become a smokescreen that hides behind the guise of fairness and simplicity but only rewards insurance payers who recognize the aging, increasingly obese population undergoing hip and knee replacements will cost more tomorrow than they do today.
However, the goal should instead be health equity whereby resources are targeted to those who need them the most, as depicted by Maguire and the Interaction Institute for Social Change.
Care should be tailored to the patient’s needs, and until the payment model reflects patient-specific issues we will struggle to achieve a sustainable system that bridges disparities and access issues for those with disadvantages.
Health insurance payers can facilitate targeted resource allocation by rewarding hospitals and surgeons who embrace complexity and enabling a system in which physicians and hospitals concentrate on the patient who needs to walk again, instead of the dollars and cents of care.
For a new grandfather with a prior history of diabetes, heart attack, and blood clots desiring to lose weight to be active with his growing family, a hip replacement can be a new lease on life.
But for some hospitals, the potential cost of a complication may exceed the fixed payout, forcing this patient to be denied and referred elsewhere. The patient is the most important part of the value equation, and without accounting for the fundamental truth that not all patients are the same, the latest evidence and government-led initiatives geared towards personalizing medicine is nothing short of theoretical.
In today’s era, we have an unprecedented opportunity.
The advent of big data and machine learning analytics offer the ability to account for case complexity and identify how much a given patient’s total hip or knee replacement should cost before surgery happens. While insurance companies primarily own this data and remain most equipped to permit targeted resource allocation, together we have the ability to build upon the systemic strengths of the “one size fits all” model by tailoring care to be patient-specific, rather than blind and bundled equality at the expense of equity.