Thursday, January 30, 2014


The name of this blog is "Why won't hospitals stop causing bedsores?". Ever since we submitted our paper in 2006 showing how a handful of hospitals had reduced bedsore incidence to near zero, we have had to wonder why all hospitals did not follow their example.

A book has just been published that explains why this may never happen unless the method of hospital compensation by insurance companies changes dramatically.  George C. Halvorson, former CEO of Kaiser Permanente, is the author of "Don't Let Healthcare Bankrupt America."  Mr. Halvorson writes:

"Pressure ulcers are a perfect example of the perverse way we pay for care today.  Seven percent of the hospital patients, on average, end up with a pressure ulcer in American hospitals.  The best hospital care sites in this country now have less than one percent of their patients getting pressure ulcers.  The very worst care sites have upwards of ten percent or their patients getting pressure ulcers.

"Ten percent ought to be regarded as an unforgivable number. Seven percent should also not be an acceptable percentage by hospital care teams. Some of the very best hospital care sites have managed to go for more than a year without one single stage-two or higher pressure ulcer. Not one.  That is amazing patient-centered, patient-focused care.

"By contrast--a lot less money is spent at the best sites, and more patients survive at those best sites....those best hospitals also make a lot less money from each ulcer patient and from pressure ulcers overall. Based on the way we buy care today in this country, the reward for doing well is to get paid less.

"...the payers who use the insurance fee schedules to define the care they pay for will cough up an average of $40,000 in fees to the care site for each pressure ulcer patient....Doing all the things needed to keep those ulcers from happening are not accepted as billable sources by the fee schedule that is usually used to pay for approved care -- so very few fee-based care sites do that preventive work....There is also no fee to have the highest risk patients in beds that have special liners.

"The care priorities and the care delivery approaches that result from a flat payment approach for a package of care can be very different than the priorities that are a fact of life for a fee-based piecework payment business unit.

"Kaiser Permanente is one of those prepaid care teams that sells care by the package and not by the piece.  With three dozen hospitals, 550 medical care sites, 180,000 caregivers, and 9 million members, Kaiser Permanente is paid a flat fee every month for each of the 9 million members, and uses that money to provide the care needed by the 9 million people....Being freed from the tyranny and structure of a piecework cash model allows the care teams to focus on the patients.

"The pressure ulcer work at Kaiser Permanente has gotten continuously better. the care model of being paid by the package rewards continuous improvement.  With that payment model, the ulcer level has dropped from 3 percent to 2 percent of patients and now it averages less than 1 percent.....Some Kaiser Permanente hospitals have not had one single pressure ulcer for more than a year."

"Patients who get these ulcers are often in great pain.  Some are damaged for life.  Some are badly disfigured.  Some die.  Getting a pressure ulcer is not a good thing for a hospital patient.

"So how does the business model we use now to pay for care deal with these major differences in performance for care sites relative to pressure ulcers?

"Very badly or very well - depending on whether you are paying for those ulcers or charging fees to treat those ulcers.

"Care actually costs a lot more at the worst care sites.  Those sites get paid more money because they deliver poor care.  A lot more cash flows to the very worst care sites. Patients are individually damaged at those worst care site and the way we buy care today, the sad truth is that the cash flow for those poorly performing care sites increases significantly as their care deteriorates."

Are our efforts to inform hospitals how the best performing hospitals are eliminating bedsores all in vain until we are able to change the business model?  Is the profit motive so strong that hospitals continue causing pressure ulcers that they know how to eliminate?

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