In 1967, when I was twelve, my mother and I rode our brand new Schwinn 5-speed tandem from Marquette, in Michigan’s Upper Peninsula, to Montreal, Canada, to attend the world’s fair, Expo ’67—in my view, the greatest ever world’s fair. That 700 mile, month-long adventure is one of the defining experiences in my life—a reminder of just how much you can accomplish if you just keep peddling.
“You can’t get there from here.”
We heard that line more times than we could count as we peddled along pulling our aluminum-frame plywood trailer. I don’t know if it was because we were on a bike, or because my mom was 50 years old and blind or because I was 12 and, well, 12. I think the real reason is because they knew they couldn’t do it so we certainly couldn’t do it either.
We heard it when we hit the Seney Stretch, a 25 mile long flat straight section of highway M-28 through the Seney National Wildlife Refuge (a beautiful ride on a sunny day full of wildlife).
It was proclaimed authoritatively by a state cop who told us we couldn’t ride our bike on the highway even though we knew we could. (Late one evening he also chased us out of a road-side picnic area where we’d pitched our tiny tent in a far corner.)
We read it on the sign that said “bicycles and motorcycles less than 250 ccs prohibited” as we rode past it to the International Bridge in Sault Ste. Marie that was our passage into Canada. (Without a moment’s hesitation, the bridge authority folks loaded us into a pickup and drove us over with nothing but smiles. Standing in the back of that open pickup holding the bike in place as we crested the bridge with the wind blowing through my hair—I felt like Leonardo DiCaprio in Titanic—“I’m King of the World.”)
And we heard it when we tried to load our gear onto the train for the last leg from the suburbs into the heart of Montreal, just before a wonderful stranger named Hazel Mulqueen said “Oh, don’t worry about them. We’ll drive you i, and you can stay at our house.”
In a car, you get into your little glass and steel bubble, complete with your packet of air, and zoom from one place to another. You can think about where you started and where you are going. In between, you watch the world go by like you’re sitting on the couch watching a reality TV show. Who has the remote?
On a bike, you live in the moment. Where you have been or where you are going is only what you can see— as far as that bend in the road, to the top of that hill,. You gauge your speed by the clicking sound of the seams in the pavement as first the front then the rear tire rolls over, and you mark your progress by the change in alignment of the trees as you look far off to the side of the road. Incremental progress is all there is, and it is enough.
“You can’t get there from here.” After a while, it made us laugh out loud before we answered softly “Watch us.”
Which brings us to healthcare reform.
President Obama has had to back away from his goal of passing healthcare reform by August and now talks of passing legislation by the end of the year. He’s adjusting expectations too, shifting the language from the broader “healthcare reform” to narrower “health insurance reform.” Now his opponents are raising doubt whether anything at all can be accomplished and threatening doom if anything does pass. We all know what we’re in for. It is the kind of political diatribe that shakes our confidence in our leaders, and leaves us discouraged, sometimes even ashamed.
Amidst the rancor of the larger fight, it is too easy to lose sight of the real opportunities that are in front of us.
The low hanging fruit in healthcare reform.
The idea is simple: Say, for example, a loved one is newly diagnosed with and treated for a chronic medical condition, like diabetes or hypertension or congestive heart failure. You hope that by the time he or she is discharged from the hospital, he/she will be reasonably stable. By reasonably stable, we mean we hope that the person won’t be admitted back into the hospital within, say, 30 days for the same condition. That seems like a reasonable expectation, don’t you think?
To put this in perspective, according to an excellent report in the New England Journal of Medicine published in April, 2009 called “Rehospitalizations among Patients in the Medicare Fee-for-Service Program,” a study of Medicare claims data for 2003 and 2004 showed that “almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days and 34% were rehospitalized within 90 days.” The report went on to estimate that “the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion.
Another report from June 2008, published by the Medicare Payment Advisory Commission (MedPAC) estimated that “Medicare expenditures for preventable hospitalizations may be as high as $12 billion a year.”
Recognizing the number and potential for savings not to mention the improvement in the quality of life, President Obama’s healthcare proposals in 2009 have made the reduction of avoidable hospitalizations an important priority in healthcare reform.
It is beyond the scope of this discussion (thankfully) to consider the specific variables that lead to re-hospitalization. They are complex. Some rehospitalizations are planned and some are simply unavoidable. Still others may on some level be avoidable but reflect people and situations that do not respond to proposed solutions.
Still, the evidence shows that systems can be developed to support patients in transition as well those receiving long-term outpatient care that can reduce avoidable hospitalizations and improve the quality of life.
According to a New York Times article from May 9, 2009, a program at Park Nicollet Health Services, a hospital and clinic system based in St. Louis Park, Minnesota, has shown considerable success. Park Nicollet invested about $750,000 per year in nurses and software to track heart failure patients after they left the hospital. “It reduced readmissions for such patients to only 1 in 25, down from nearly 1 in 6.” It is estimated that the annual savings to Medicare through this program was about $5 million per year.
But the program was a big loser for Park Nicollet. Not only did they incur $750,000 in unreimbursed cost, but their very success reduced their revenue for reimbursable services! They simply could not afford to continue this successful program at the desired levels.
If Park Nicollet is representative of the cost/benefit relationship applied to the total potential savings from reducing avoidable hospitalizations, it would mean that an annual investment of less than $2 billion in outpatient follow-up could result in a net savings over $10 billion per year. As Senator Everett Dirksen used to say, “A billion here and a billion there and pretty soon you’re talking real money.” While we have suffered some degree of inflation since Senator Dirksen’s famous quote, I think he’d say it certainly applies in this instance.
So where’s the problem? It is obvious. Doctors and hospitals are paid for services rendered, not for services avoided. As Dr. Barry M. Straube, the chief medical officer for Medicare is quoted in the NY Times article, “Ultimately, we have a reimbursement system for health care that is not aligned all the time with providing high-quality care. Unequivocally, there has to be payment reform.”
So, as we consider the long term objectives of healthcare reform, let’s start with a modest little piece of payment reform that has the potential to yield savings in the $10s of billions of dollars per year. Let’s make funds available for nurse navigator and outreach programs that help patients in transition and in long term outpatient settings, and let’s use the Stimulus funds to optimize the tools and techniques that improve health while reducing avoidable costs. (We’ll discuss these systems in more detail in our next post.)
So, as President Obama and the entire Congress travel down the long road of healthcare reform, I hope they’ll focus on the narrow opportunity right in front of us, and as the naysayers proclaim “You can’t get there from here,” I hope President Obama smiles as he responds with a quiet “Watch me.”