I'm sure you were as surprised as I was that in all the recaps of the top news of 2011, no one mentioned the beard I started back in October. After all, the last time I had hair on my face was 1971 when I thought growing a goatee was an act of civil disobedience. I thought, "I'll grow hair on my chin and that'll show The Man." I don't remember exactly who The Man was anymore, but this time around, my facial hair isn't so much a protest against social injustice as an attempt to steal 10 more minutes of sleep in the morning.
And, I admit it: I also hoped it might make me seem a tad younger, or at least not quite this old. That hope was squashed when I visited my mother over the holidays and she repeatedly mistook me for my Uncle Miles. "Your beard makes you look exactly like your Uncle Miles," she kept telling me. When I pointed out that Uncle Miles is more than 20 years older than I am, she just nodded and said, "It's uncanny."
Can you say, "unintended consequences?"
In health care, we know all about unintended consequences. A breakthrough medication to alleviate one ailment triggers another, more serious one. Clinical IT devices save lives by warning nurses and physicians that a patient might be in harm's way but issue so many trivial alarms they're often ignored. And remember managed care? It was so riddled with unintended consequences that the only thing it really managed was to rile nearly everybody up.
Keeping an eye out for repercussions we did not foresee and do not welcome will be critical as we move deeper into the implementation of health reform in 2012. One goal of reform is to "bend the cost curve" by identifying inefficiency and waste in care delivery. And one place insurers and policymakers see a lot of waste is on the money spent caring for patients who then die. However, in a thought-provoking New York Times essay last month, Peter B. Bach, M.D., illustrates how the issue is not as cut and dried as you might think.
Bach notes that Dartmouth researchers rank hospitals and states "based not on how successful they are at preventing the deaths of patients who are very ill, but on how much they spend on those they fail to save." But emergency department doctors, for instance, can't always know if someone coming in with a dire condition will survive; he cites one of his own patients who a supervising physician predicted would soon die but who nevertheless was given immediate, intensive care. The patient survived and walked out of the hospital three weeks later.
"How could it be that we were prudent with health care dollars because he lived, but would have been described as wasteful had he died?" Bach asks.
Bach, director of the Center for Health Policy and Outcomes at Memorial Sloan-Kettering Cancer Center and a former senior adviser at CMS, says the policy conceit that spending money on patients who die is a waste overlooks a key correlation in health care. "When people get sicker, they need more intensive — and expensive — health care services," he writes. "But when they are sicker, they are also more likely to die."
Bach acknowledges that some treatment is too aggressive and unwise. The trick is coming to a shared understanding of which patients should be given the most aggressive treatment and which should not. Getting there will be politically difficult, with someone no doubt raising the "death panel" canard, "but leaving the distinctions to individual doctors leads to inequities, harm to patients, distrust in medical care and lawsuits," he writes.
It's useful to read the entire essay, "When Care Is Worth It, Even If End Is Death," to understand why we ought to consistently question conventional wisdom if we really want to change our health care system for the better.
Bill Santamour is managing editor of Hospitals & Health Networks. You can reach him at firstname.lastname@example.org.