The Cost to Value Conundrum in Cardiovascular Healthcare Provision
Author: Larry H. Bernstein, MD, FCAP
I write this introduction to Volume 2 of the e-series on Cardiovascular Diseases, which curates the basic structure and physiology of the heart, the vasculature, and related structures, e.g., the kidney, with respect to:
1. Pathogenesis
2. Diagnosis
3. Treatment
Curation is an introductory portion to Volume Two, which is necessary to introduce the methodological design used to create the following articles. More needs not to be discussed about the methodology, which will become clear, if only that the content curated is changing based on success or failure of both diagnostic and treatment technology availability, as well as the systems needed to support the ongoing advances. Curation requires:
- meaningful selection,
- enrichment, and
- sharing combining sources and
- creation of new synnthesis
Curators have to create a new perspective or idea on top of the existing media which supports the content in the original. The curator has to select from the myriad upon myriad options available, to re-share and critically view the work. A search can be overwhelming in size of the output, but the curator has to successfully pluck the best material straight out of that noise.
Part 1 is a highly important treatment that is not technological, but about the system now outdated to support our healthcare system, the most technolog-ically advanced in the world, with major problems in the availability of care related to economic disparities. It is not about technology, per se, but about how we allocate healthcare resources, about individuals’ roles in a not full list of lifestyle maintenance options for self-care, and about the important advances emerging out of the Affordable Care Act (ACA), impacting enormously on Medicaid, which depends on state-level acceptance, on community hospital, ambulatory, and home-care or hospice restructuring, which includes the reduction of management overhead by the formation of regional healthcare alliances, the incorporation of physicians into hospital-based practices (with the hospital collecting and distributing the Part B reimbursement to the physician, with “performance-based” targets for privileges and payment – essential to the success of an Accountable Care Organization (AC)). One problem that ACA has definitively address is the elimination of the exclusion of patients based on preconditions. One problem that has been left unresolved is the continuing existence of private policies that meet financial capabilities of the contract to provide, but which provide little value to the “purchaser” of care. This is a holdout that persists in for-profit managed care as an option. A physician response to the new system of care, largely fostered by a refusal to accept Medicaid, is the formation of direct physician-patient contracted care without an intermediary.
In this respect, the problem is not simple, but is resolvable. A proposal for improved economic stability has been prepared by Edward Ingram. A concern for American families and businesses is substantially addressed in a macroeconomic design concept, so that financial services like housing, government, and business finance, savings and pensions, boosting confidence at every level giving everyone a better chance of success in planning their personal savings and lifetime and business finances.
http://macro-economic-design.blogspot.com/p/book.html
Part 2 is a collection of scientific articles on the current advances in cardiac care by the best trained physicians the world has known, with mastery of the most advanced vascular instrumentation for medical or surgical interventions, the latest diagnostic ultrasound and imaging tools that are becoming outdated before the useful lifetime of the capital investment has been completed. If we tie together Part 1 and Part 2, there is ample room for considering clinical outcomes based on individual and organizational factors for best performance. This can really only be realized with considerable improvement in information infrastructure, which has miles to go. Why should this be? Because for generations of IT support systems, they are historically focused on billing and have made insignificant inroads into the front-end needs of the clinical staff.
I do not have an in detail information about the ACA. However, from a very general point of view it seems that it tries to complement those existing forms of health care provision systems without replacing it with state owned new one.
Private owned health care providers are a source of constant pressure that tends towards lowering costs. This a weak point in state owned health care providers. However, in some cases lowering costs alone crossed the lines that separate rational decisions from less rational ones. In this case, the existence of both systems provides a better scenario for evaluation of medical procedures that in the case of the private system only, would be excluded. On the other hand, the same situation with both sources of health services (private and public systems) provides a general reference for reasonable costs that is absent in state only system if properly accessed the data offered by the two systems.
This dual system could work very well in case it also counts on an independent scientific form of evaluation of best medical procedures and products. The scientific establishment also has suffered with the increase importance of private producers of scientific equipment and techniques detached from scientific end-users. These private producers despite of the fact that they are a strong innovative force also, work in unrestrained forms and therefore can affect in negative way science itself when impose form over content. It is possible to imagine a condition in which a very sophisticated technique is employed to produce an enormous amount of data without any real gain in our ability to increase our scientific knowledge while on the other hand; a new scientific finding is obtained by very primitive method. In case the two scientific workers dispute over a political position related with medical care it will be far more ease for the first one to convince lay people than otherwise.
This work on Cardiovascular Health care provision seems to be a first step on the right direction.