Commentary on Elliott Fisher's Proposal for Medicare

There is a suggestion by Elliott Fisher of Dartmouth Med School that the Commonwealth Fund recently put on the web as to how to cap Medicare costs, diminish unnecessary tests and procedures, and take geographical diversity into consideration.

Fisher would consider the hospital and the patient’s principle doctor as a unit and, as I understand it, compare their combined charges per DRG with those of the region they are in. Those units coming in under the mean would be rewarded; those over we not be rewarded. It is thought that this would simplify the billing and evaluation processes by greatly reducing the number of providers by looking at hospitals including their providers rather than hospitals and providers separately. . All the treating and referring docs in one hosp plus the hosp would be evaluated as one team. Medicare will like that.

The idea is to diminish costs by rewarding those who treat efficiently and don’t run up costs with unnecessary tests, procedures and admissions. Not a new idea- one can consider cost caps, as as an incentive to efficiency. What has resulted from cost caps are cutbacks in servies, increases in complexity of treatment, and other cost override games. And without good metrics of severity and complexity and a strong outcomes measures in place, this program would might lead to a deterioration of care as the team makes sure they do the stuff on the lists: mammograms, colonoscopies, vaccinations and beta-blockers, but scrimps on the rest to come in below the mean cost. In addition the complex patients might all find themselves underserved or dumped into another unit, or as Fisher calls them, extended hospital medical staff, (EHMS). We would be rationing care to make the cut, as teams.

The plan, since it’s measures success regionally and relatively, might tend to promote the regional excesses of intervention so stunningly revealed in Wenberg’s Dartmouth data.

The teams, the EHMS, would seem a good idea but with qualifications. First, the team members must be monitored individually by its EHMS, to wean out incompetents and privateers. The overall system should rapidly rank the units. It is a must that the variations in the patients being cared for are fairly calculated so comparisons are just. That will require some fancy date collection and analysis of date, possible with today’s computers. Outcomes should be part of any payment scheme. In a non-fee-for-service circumstance, such as DRG’s create, it is frequently better to under treat than to fully treat since outcome ignored. We collect readmissions but do little about them reimbursement-wise. And Fisher’s plan would be even more attractive if it got away from regionalism and let all Americans have a chance to go somewhere better for treatment. Let the units compete nationally, as Porter and Teisberg have suggested. And as they have said, we should reward value.

Prof. Fisher’s plan needs to be more fully sketched out, but with qualifications it seems a progressive step. Medical individualism has proven itself to be too expensive. Team innovation may be the answer.

Eric L. Radin, MD

The Fisher proposal is described at: (http://www.cmwf.org/healthpolicyweek/healthpolicyweek_show.htm?doc_id=424115&#doc424117)