We are working on a proposal for a cooperative agreement with CMS as part of their CMS Healthcare Innovations Challenge in which they are allocating $1B (yes that’s one billion dollars) to 3 year implementation efforts to meet the “triple aim” of improving healthcare, improving health outcomes and reducing costs. Â Doing all 3 of these at the same time is a real challenge, as pointed out by a recent Federal report that found that so far, most efforts to meet the triple aim have improved healthcare and/or health outcomes, but they have increased costs!
Our system of fee for service is a real problem in that regard.  Consider that African American patients in our region have a very high rate of amputation due to peripheral arterial disease.  This, of course, is a source of expertise for our hospitals and vascular surgeons. If you needed an amputation, you’d want an expert; to become an expert requires volume, and we’re producing volumes by failing in our efforts to treat diabetes effectively.  We also know that treating diabetes more effectively will involve an upgrade of outpatient service, including more home visits and follow-up by advanced practice providers (NPs, PAs).  These services are not well reimbursed and, on balance, lose money. Since many African American patients are less well off, the cutbacks in funding of Medicaid and Medicare impact this situation even more.  On the other hand, amputations make money!
It seems clear that we want to reduce amputations while maintaining the expertise that is so valuable to all patients from high volume procedural specialists. Â This would require more centralization of procedures and a change in payment to enhance valuable outpatient services. Â Or, it is likely that we will continue to reinforce a system that is associated with a decline in our national health status relative to other economically developed countries.
We have a team, including Dr. Susan Spratt, dedicated to reducing amputation rates, but I’ll bet they would be more successful if they were swimming downstream instead of battling the upstream currents!
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