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last week we talked about a study from the journal of the american medical
association which talked about more
profit for hospitals when there are complications to surgery and joining me
to talk about that is doctor andrew gonzales he's asleep health services
research fellow
at the university of michigan also a resident physician in general surgery at
the university of illinois hospital and health sciences system
so doctor gonzalez's first question is justin to make sure i fully understand
what this is saying
understand that when
somebody has a complication from surgery
more things need to be done therefore the total number of dollars of profit
may increase but did the study say that
the profit margin the rate of profit also is higher when there are
complications
yes that's true so they worked out soooo measures of marginal total margin
which include spoke but that's not variable cost and then they won't uh...
the our contribution margin which is just the
her patient variable cost
so in both instances the profit margins increase
for uh... especially for private payers
okay so the other thing that i didn't see
in the different
uh... uh... uh... articles about this study but maybe it was in there was
went when we talk about a surgical complication i could imagine situations
where
their complications there arise
from medical air right physician air
or simply that some percentage of patients are not going to recover or
have kind of the
thus most straightforward course of treatment that others might have so did
this study applied to both of those wasn't only medical errors are or what
will happen is that
well yes a very good question did it so i'll
when you're looking at
errors after uh... surgery a lot of people don't even out the difference
between a bad alcon and err on the part of the house for the position exactly
correct
the outcomes that they looked at specifically or physical site
inspections
wound he has since
pulmonary embolism started tax protest being on the ventilator longer
then out three days
so when you look at these out cause the problem is that a lot of them on michael
retained foreign object like they did a sponge inside of the patient
can necessarily be attributed holy to the patient four full weight of the
position
somethings are partially a measure of patients status
for instance people who have a lot of diabetes have higher rates of surgical
site actions
so for than it makes it a little difficult to to kind of parse out
what a solution is because if if we were talking only about situations where
they're of medical errors right
in those cases it would seem that it does not make sense for hospital profits
to go out for the hospital essentially to be rewarded
for something that could've been avoided if they did the procedure correctly but
we're we're talking about both situations right also situations where
because of the patients circumstances
they may be more prone to complications so given that
what's your assessment of this and what can we what can we deduce what are we to
said to take away
from the fact that profit goes up when they're complications
and then we can kind of talk about what may be would be changed but what what
should we be really taking away is the problem here
so i think that our system of medical payments
probably needs to be modified
one thing that
was passed under the uh... affordable care act was what's known as on looking
at
so under this payment system
stayed basically jd
give the hostility for the episode of care
and whatever the hospital does with that money is left more or less up to the
hospital so they're not paying for individual operations so the hope
all of this is that winner date give these episode payments at hospitals land
upbeat using cost will increase increasing quality
so that would be for example somebody comes in for an appendectomy
and regardless of what
ben's chili needs to be done to get that patient
out of the hospital discharge
there's kind of like a set amount but i guess we depend on the patient ajun
maybe some other kind of
of of variables that with the term and what is kind of the total payment you'll
receive
and then the hospital in that case would have a higher profit higher profit
margin
if they have a good outcome with with less complications as that is that right
yes that's absolutely correct that
is the uh...
basic idea behind on payments that are
based upon episodes sometimes there may be elected severity modification so if
you come in with autobot shirt and the scientists then he possible to get more
money because they're so save more complications and more thier but that's
the central idea
so i'd like the idea of kind of incentive ising
proper care from the start and kind of rude that did not not doing this thing
work for everything you can add to the bill
you're making more money that i like but my concern is
could you not have a situation then
where the hospital may
not provide
the care that be the that not not the bare-bones minimum all of that would be
done but you might have certain situations where the hospitals imps
because they know that what they're going to receive is fixed and there may
be ancillary care or things which may be done
otherwise that the hospital would avoid doing ten not kind of short change
themselves is that possible over the fact that
those things would be more likely to result in complications kind of the its
own safeguard
right that you haven't heard feedback loop in the politically mechanism
because of something truly improves alfonse hospitals are incentivize to of
going after this uh... signal policy so for instance rehab after surgery in
cases where patients really need rehab after surgery holes would be much more
likely to provide for even if it's an additional expects
slots the of pablo cannons only covers a limited time after surgery
right now i believe the incentive programs are for thirty days after and
three days before so depending on that you may end up winding into a a a new
bond also brings its postoperatively acts along the course that was more
complicated but under these systems the quality is what's being incentivize and
in theory beyond hospitals have no incentive to skimp on services
that are essential for patient care
so give us an overview of where is this type of payment system being implemented
currently where will it be implemented
so currently
it's inot the pilot phase inch won t fifteen my memory serves me correct
uh... gets rolled out outside of the pilot phase
so basically right now it's all opt-in system
uh... unfortunately some of the
pilot data may not be widely generalize bolts because obviously health systems
that are uh... vertically integrated that have all are different types of
services are much more likely to be able to uh... huh
make use of this if you're a kind of a single community hospital that doesn't
have
a rehab at only has alerted circle services and comes much more difficult
for you to ponder payments ball it into something like icing near or the mayo
clinic or any integrated health system
well it makes perfect sense plus incentivize proper treatment from the
start and reduce reduce complications that i think next the next conversation
we have dr gonzalez should be
why is it four hundred and forty dollars for me to see a urologist for seventy
five seconds but that's probably that that's a bunch of broderick conversation
if i don't have time for today right
absolutely that is a
stopping in itself
alright has become a doctor andrew gonzales hope health services research
fellow at university of michigan
also a resident physician in general surgery at the university of illinois
hospital and health sciences
system thank so much for talking to us about this today
thank you so much