WASHINGTON There has been a lot of talk, but little done on the national level to address persistent problems in the health care system, according to experts speaking at a conference to release the results of the latest edition of a survey of hospitals and physicians across the country.
When the survey was last conducted 2 years ago, several troubling trends were identified. At the time, there was an ongoing hospital building boom, intense and sometimes acrimonious competition between hospitals and physicians over specialty services, growing stress on community safety net providers, and inadequate cost-control strategies on the part of employers and health plans.
The conclusion: These trends were creating a two-tiered system in which individuals with health insurance had better access to high-cost care and those without had diminishing access to any care.
"For the most part, these trends have continued into 2007," said Paul Ginsburg, Ph.D., president of the Center for Studying Health System Change, which sponsored the conference and conducts the survey of health care sites in 12 communities every 2 years.
The dichotomy between the haves and have-nots is also appearing among physicians, said Dr. Hoangmai Pham, senior researcher at the center. A growing number of specialists are working exclusively through private hospitals or ambulatory care centers, where they can dictate their hours, don't have to deal with paperwork, and are largely insulated from nonpaying patients. In contrast, many community-based physicians are being shut out of the hospital altogether.
"In many of our sites it's now the norm for most inpatient medical care to be provided by hospitalists. This has led to much more fractured relationships with community-based, primary care physicians and the hospitals that they used to know," she said.
While these trends continue, reforms on the national level have been incremental and modest, such as expanding access to health savings accounts and encouraging more consumerism in health care. That may reflect an apparent disconnect between the level of debate in Washington and what is going on in the field, said Dr. Robert Berenson, a senior fellow at the Urban Institute.
Speaking at the meeting, he recalled a conversation with a physician during a visit at one of the survey sites: "I asked him how's the weather and he launched into, 'What are you people in D.C. drinking? Your fee schedule in Medicare is absurd, and what you're doing to us is making it impossible for us to hire cardiologists. They want to stay in the fee-for-service sector because they are making so much money.'"
Such distortions in the reimbursement system have created perverse incentives that are helping to drive many of these troubling trends, said Don Fisher, Ph.D., president and chief executive officer for the Medical Group Management Association. "The more you do, the more you get paid. Said differently, the worst quality care in this country gets paid the most," he said.
While paying more for poor quality, the current system also punishes innovation.
"Every quality improvement you make on the ambulatory side that reduces the hospital admissions and readmissions… causes a loss in revenue to that institution, to that hospital, large losses of revenue," Dr. Fisher said.
Yet, many institutions are pushing forward with quality improvements anyway, he said.
However, policy makers in Washington may be missing out on that fact. He cited one hospital he visited during the center's survey. The chief medical officer couldn't come up with any quality measures they had implemented, but mentioned that they had recently installed a Tele-ICU.
"That's at least equally significant in the area of quality and safety, but we in the policy world have said quality and safety is about these heart attack measures and congestive heart failure measures," he said.