|By Savannah Tranchell|
Long before the bitter debate over the federal law, most of which was upheld by the
Insurance based on employment -- you could lose it if you're too sick to work -- and the fee-for-service system --paying doctors and hospitals for doing more stuff, even if it's the wrong stuff -- have created incentives that push in all the wrong directions, many say.
Determined to reverse course, hospital executives, clinic administrators and physician groups have been doggedly pursuing ways to lower costs by changing the incentives that drive the health care industry.
"We all agree, I think, that the current fee-for-service model has all the wrong incentives in it," said
The work to curtail costs and improve quality has required an alliance of strange bedfellows: insurers, government officials and private providers, in the past often found on opposite sides of a negotiating table.
No one thinks it will be easy to wrestle the lumbering, fragmented and tradition-bound health care industry into a form that rewards quality and efficiency -- not quantity -- of care.
These local leaders are buoyed by some early successes.
One collaboration between hospitals around the state and the
The goal, said
Other public-private collaborations, some convened by Gov.
Insurers and providers have worked together, rejiggering the typical payment model to shift incentives toward keeping people healthy instead of just running up bills when they're sick.
One ongoing agreement between major insurer
Some other changes under way seem small -- Swedish asked cardiologists to agree on a single vendor for catheters and other hardware about four years ago. But Brown, the CEO, said there are "enormous savings" there, as well as benefits to patients.
"The more variability there is among surgeons, at the end of the day, the less good the outcomes are," agreed Dr.
Despite these successes, health care leaders are hardly sanguine about the task ahead.
At this point, to survive in the current market, medical centers have had to woo well-insured patients, building state-of-the-art facilities and promoting high-tech specialty care. But there's no high-tech solution to health care's fundamental problems.
"We know we have to improve access to care, and we know we have to dramatically reduce the cost of care," said Brown, of Swedish, which ended 2011 with a
The hospital made dramatic changes, including reducing staff by about 1,000 workers and affiliating with the much-larger
As for doctors, most understand the current system is not sustainable, said
Some say it's the private marketplace's last chance.
If the health care industry itself fails to solve the problem, said
"This might be one of the last opportunities for the marketplace - - providers and insurers -- to sort out solutions," Cooper said. "The next logical step, which many of us have not wanted to consider, is a single-payer system."
Not law's focus
The Affordable Care Act, which relies on private insurance, for the most part doesn't directly address costs.
At the same time, it seeks to alter the course of health care delivery, most notably by changing at least some of the dynamics that have contributed to financial and ethical troubles for U.S. society.
Instead of a system in which people can skip buying health insurance when they are healthy and insurers can refuse to cover them when they are sick, the federal law makes two important changes, beginning in 2014.
It requires everyone who can afford it to carry insurance or pay a penalty, and bars insurers from denying coverage to people with health conditions. For those who can't pay, the law expands
More than a million Washingtonians are now uninsured, according to state insurance statistics. Many skip routine care they need, waiting until their condition worsens and they're forced to rely on hospital emergency rooms. That runs up costs that eventually get piled onto the premiums paid by those who are insured and by businesses, which increasingly say they can't afford to insure their workers.
In many ways,
In the public realm,
As a result of these and other programs, Washington Medicaid's cost increases over the past several years have been in the 2 percent to 3 percent range, compared with national trends of 7 to 8 percent or more, says Thompson.
But nobody believes that's enough.
Some say the federal law doesn't do much to control costs, although it makes a number of small but important tweaks, encouraging care improvements that may ultimately save money.
For example: It removes patient costs for many kinds of preventive and diagnostic care, such as mammograms and colon-cancer screening. It also allows a new type of payment arrangement in which clinics and doctors would be rewarded for helping keep patients healthy.
"This thing from the
Why didn't hospitals, doctors and other health care leaders work harder in the past to control costs, improve quality and shift incentives?
"We should have," said Westcott. "We wouldn't be in such a mess today if we'd done it." But the medical culture, he added, wasn't ready.
"In medicine, everybody has just done what they wanted to do."
Now, Westcott says, most see the writing on the wall.
A lot of writing.
Many look to models such as
"We know that health care is going to transform over the next four or five years to much more of a managed-care type model where we're very, very accountable to costs," Westcott said. "All of our organizations are really trying to learn how to do this."
Now, the relentlessly bad economy is creating urgency.
Unemployment remains high, and many people have lost insurance. Some can't pay for the medications doctors prescribe.
A wave of baby boomers is about to hit overworked primary-care doctors, who worry about the younger generation, too.
Plagued with high rates of obesity and diabetes, today's young people are likely to be the first generation less healthy than their parents, says Curry, of the
Without changes, patients with chronic conditions and terminal illnesses will continue to get care that is expensive but not necessarily helpful.
"You know what's got to be done," Curry says, "but getting there isn't going to be easy."
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