Sunday, January 3, 2010

Bundle Me Up

Hooray! Bundling is coming! The answer to all our problems! No more shall we be charged excessively for medical care! Now doctors will finally have an incentive to cure patients as quickly as possible. How could this possibly be a bad thing? How?

What in the world is bundling, you say? Bundling as it refers to healthcare in general is when you offer one price for a general treatment. It is similar to construction and contract work with a major difference. Let’s say you hire a contractor to refinish your basement. He comes by, looks over the basement, and gives you an estimate. You make a deal and sign a contract. But when he starts taking down the old drywall, he discovers mold. Now he will have to seal the foundation cracks and lay new insulation and drywall. It will take him longer and he will need more materials. And of course this will cost you a lot more. But your contract was for a refinished basement, you say? Unfortunately, your contract did not cover mold and foundation work, even though it is needed to accomplish the final goal of a refinished basement.

Bundling in healthcare is just like that, only the contract does cover just about everything that is needed to accomplish the final goal. Imagine if that were true in contracting. We need to rebuild the foundation and so we need to rebuild the entire house to refinish the basement? You got it at no extra cost. That is how it is in medicine. If you get admitted for pneumonia, there is a net reimbursement for that, calculated by oxymoronic government geniuses. That reimbursement is split up between the hospital, doctors, and everyone else involved in the admission. Need to stay in the hospital longer because you are improving more slowly than most people with pneumonia? No problem for you. The hospital and doctors, however, will not get paid for those extra days because the money will have been spent.

That is not the spirit that bundling is trying to capture. Imagine another scenario where you are in the hospital for appendicitis. You get an appendectomy. But then you develop a hospital acquired urinary tract infection. Or a hospital acquired pneumonia. These things do happen, and are not unexpected. There are people, however, that believe they should never happen. Period. And because of that belief, there is a move to deny payment for any treatment or tests done due to a hospital acquire infection. And if they have it their way, any hospital acquired anything, save a regrown limb on an amputee. The spirit of bundling in that sense is reasonable. If your contractor breaks a window while bringing two by fours into your house, you should not be responsible for the cost of the new window or the labor to install it.

What are the consequences of bundling, then? There are two obvious outcomes. The first is that you will have doctors that will continue to treat you for no more money even as your case gets more complex. The second is that you will have doctors who will do only enough to get you seemingly better so they do not end up working for free. But even in the first scenario you will have problems because the hospital will not be able to eat the costs of hospitalization beyond doctor’s fees for very long if they are not getting paid for it. And there are movements to deny payment for subsequent hospitalization if they are for identical causes. For patients this would certainly be a good thing. We can throw around terms like “accountability associated reimbursement” and “standardizing healthcare”. The public will eat it up. It sounds as though everyone will get equal care. No more worrying about whether you have a good doctor or not, or if you are at good hospital or not. Who needs a doctor to run an algorithm? We can use cheaper nurse practitioners. And if people would give up their bias of having people with a medical background run the algorithm, we could even train a monkey to run it.

In very large institutions, that is exactly what will happen. Care will become standardized. Protocols will be written. Many many protocols. So many, in fact, that it will make the government look like a two year old deciding what to eat. People will be diagnosed based on the constellation of reported symptoms and basic labs and imaging and then fed into a treatment algorithm. These protocols will be based on the average patient—average length of stay, average number of comorbid conditions, most likely diagnoses, and so on. And this will work just fine—for the average person. What if you are not the average person? What if you actually have lung cancer that is manifesting as a productive cough? Chances will be more likely that it will be missed with bundling. And what if you do get diagnosed and get admitted with pneumonia because of chemotherapy? Should you expect that your case will be treated differently than the college kid with walking pneumonia? The answer is yes, you should expect it, and it will be in the beginning. But as these cases accumulate over time and the doctors continue to care for them with little reimbursement because of bundling, the hospital will also begin to bleed money because of little reimbursement. Most hospitals are already in the red more often than not, and this will make it worse. Eventually, either the doctors will stop working or the hospital will shut down. I bet the latter will happen first. Then care will be completely standardized—no care whatsoever. What a great big bundle of joy reform will bring us.