Thursday, September 25, 2014

Is the Pressure Ulcer Problem Solved?

We have discussed here earlier the fact that the former CEO of Kaiser Permanente, George C. Halvorson, in his book Don't let Health Care Bankrupt America, points out that pressure sores can be eliminated when hospitals have the right financial incentives.  "Cash flow has an incredibly powerful impact on the delivery of care.  The specific ways that we channel the flow of cash to caregivers in this country dictates almost all of the care that is delivered by those caregivers."

He points out that most hospitals are paid by an insurance company on a fee schedule for each service performed, so that services for pressure ulcer treatment improve cash flow.  But in a system such as Kaiser Permanente, where the hospital is integrated with the insurance company so that an upfront payment is made for the care of each patient,  the expenses of pressure ulcer treatment subtract directly from hospital profit.

Kaiser, in its over 30 hospitals, has reduced pressure ulcer incidence to under one percent, and many of its hospitals have reported no ulcers in several years.  The IHI has a list of a dozen mentor hospitals that have achieved one percent or lower incidence rates.  And a number of hospitals that have virtually eliminated hospital-caused pressure ulcers are described on the webpage of the National Decubitus Foundation (

It has been reported that there is now a trend toward a Kaiser-like payment model that is "moving quickly like a wave on a beach".  This week the New York Times reported on a new health system that may represent the most important manifestation of this trend to date:

"In a partnership that appears to be the first of its kind, Anthem Blue Cross, a large California health insurance company, is teaming up with seven fiercely competitive hospital groups to create a new health system in the Los Angeles area. The partnership includes such well-known medical centers as UCLA Health and Cedars-Sinai.

"Anthem and the hospital groups plan to announce on Wednesday the formation of a joint venture whose aim is to provide the level of coordinated, high-quality and efficient care that is now associated with only a handful of integrated health systems like Kaiser Permanente in California, Intermountain Healthcare in Utah and Geisinger Health System in Pennsylvania.

"The venture comes at a time of sweeping change in health care, set in motion by the federal Affordable Care Act and intense pressure to reduce the cost of care. Many hospitals are responding by merging and buying doctor's practices, while some are beginning to offer their own health plans for the first time.

"The plan represents a potential alternative in California to Kaiser, popular in the state and a pioneer in managing patient care through sophisticated electronic health records. I think its got the potential to operate very much the same way as Kaiser does said Ms. Boynton, who said many public employees now choose Kaiser.

"Joseph Swedish, the chief executive of WellPoint, the large commercial insurer that owns Anthem and other Blue Cross plans, says the venture is a result of the demand by employers that insurers and providers work more closely on finding better ways of delivering care. This integrated approach I would call game-changing in the Los Angeles marketplace, he said.

"While WellPoint and other insurers are experimenting with alternatives to the current practice of paying doctors and hospitals based on the volume of services they provide, hospitals in the joint venture have agreed to provide care at or below their cost and will share in all of the financial results.
The hospitals must meet certain quality standards to ensure that they are not stinting on care. But Pam Kehaly, a senior executive for Anthem, said the venture was expected to produce significant savings and profit by reducing unnecessary tests and unneeded hospital and emergency room admissions."

Clearly we know how to prevent pressure ulcers when the financial incentives are there.  We must now concentrate on seeing to it that the trend toward integrated healthcare systems continues.