The Illusory Bottom Line

By Joe Flower	July 21, 2011
Why cost-cutting has never really worked, what will work, and what is already working.

Cutting costs does not cut costs. If we hope to steer health care toward a better cheaper future, we have to wrap our minds around this conundrum: Slashing spending does not necessarily improve the bottom line.

Governments in Ireland and the United Kingdom have come up hard against this conundrum. They both have faced soaring deficits due to the economic downturn, because their tax revenues have fallen at the same time their costs for unemployment and other kinds of social support have risen.

So they both did what might seem like the sensible thing. They attacked the problem by cutting spending, in the professed belief that such a move also would increase the financial markets' confidence in the future, and thus pump up the economy, reduce unemployment, reduce the interest the government has to pay on its debt, and increase tax revenues.

Result? Their deficits have grown even larger. Why? Because what economist Paul Krugman likes to call "the confidence fairy" never showed up. The austerity measures tanked their economies even further. Firing a lot of people, it turns out, drives unemployment up and tax revenues down. The worsening debt picture increased the cost of borrowing. Many U.S. states are headed down the same path right now, slashing spending in order to slash deficits, and the U.S. Congress is famously and forever wrangling over the same formula.

Aim at Foot; Pull Trigger

What is to notice here, from our perspective, as people who run health care systems? Two things:

• This conundrum (spending cuts lead to increased spending) happens when an entity cuts spending that is an input to the larger system to which the entity is responsive.
• This is a pattern that repeats in one way or another at all scales in the economy: national governments, states and provinces, health systems, individual businesses.

So a government cuts spending drastically, lays off workers, reduces salaries and restricts unemployment benefits. But a cut in spending by the government is a drop in income to the economy as a whole, the very economy on which the government depends for its tax revenues and its borrowing ability. A state finds that its austerity spending program helps drive down its tax revenues, and drives up the number of people applying for Medicaid and other support programs.

A business faced with a fall in sales lays off workers and cuts back investment in new equipment, inventory and its sales force, and finds that sales decline even further, while it has narrowed its own ability to respond with new products, more efficient and innovative production, or new revenue streams.

A health system responds to cuts in reimbursement levels and shifting payer mix with the same tactics?laying off people and cutting back on new investment?and finds that it actually has decreased its efficiency, increased costly mistakes and cut its ability to respond with new initiatives and revenue streams.

Health Systems: More Complex

But the cost situation of health systems always has been much more complex than that of other businesses, and traditionally has been drastically different for one simple reason: Health care providers have been able to decant their excess costs to customers and payers.

In a fee-for-service system supported by public and private insurance, the reimbursements contain the cost inefficiencies of the system. Reimbursements are based on various formulas, and negotiations are based on the formulas. These, in turn, are based on a number of factors, including such things as a vague idea of how different items generally are priced in a given market, what they cost last year, how much should be allowed for system overhead, and how able the payer is to beat up on the provider.

These negotiated reimbursements have not been based on any actual accounting of the incremental cost of producing the service in a given setting. In fact, in the past, most systems have been incapable of producing any such realistic cost accounting. And there has been little real competition of the type that would demonstrate how efficiently a particular product or service could be delivered.

Hospitals and health systems always complain that the reimbursement is far too low; the payers complain that it is too high. Providers have dealt with the reimbursement squeeze by trying to cut costs in general, through strategic moves to change their payer mix (such as building facilities in growing suburbs and closing facilities in poor areas) and to perform more of well-reimbursed procedures and less of poorly reimbursed ones.

Overall, though, since health systems have continued to survive, we can conclude that the reimbursements have included the cost of their inefficiencies. If they did not, if payers were only paying for what a service would ideally cost in some ideally efficient system, we all would have closed our doors long ago.

No More Cost Decanting

That's changing. Health care providers no longer can assume that they can decant their costs to the payers. Let's take a look at how, exactly, that is changing.

There are three ways to cut costs in treating a given patient, and they are quite different in their effect on the provider's bottom line. These three ways are efficiency, coordination and avoidance.

Efficiency relates to unit costs: How much does it cost to administer a given procedure or test (such as foot amputation for a diabetes patient)? In a fee-for-service system, being more efficient at each service is always a net gain for the provider. Whether the service is not really necessary or helpful to the patient, or even damages the patient, does not show up on the balance sheet. What shows up is whether you can produce the service for less than the average reimbursement for your payer mix.

The more fruitful economic strategy is the one that hospitals have followed for years: Determine which outcomes already are being delivered at a cost substantially below the reimbursement, and do more of those; do less of those that are delivered at a loss. That's a lot easier than doing the hard work of becoming steadily more efficient at all your processes.

Coordination relates to bundled costs: How much does it cost to produce a particular solution to a problem (such as the entire foot amputation bundle, from intake and diagnosis through imaging, anesthesia, operation and post-op care, through discharge and maintenance care)? Can we deliver this solution at the right level of acuity? Can we avoid duplicating services?

Avoidance relates to solution costs and system costs. Solution costs answer a different question: How much does it cost to solve the whole problem, including all possible solutions, such as aggressive early treatment of the foot abscesses, to avoid the need for amputation? System costs answer an even wider question: How much would it cost to prevent the problem in the first place through aggressive management of the diabetes, including regular foot exams?

The Cost of Avoiding Costs

Take, for a moment, these few examples:

Complex back fusion surgery for simple chronic back pain, which works no better than simple decompression, yet costs up to 10 times as much and kills twice as many people. Any surgery for simple chronic back pain has proven no better than medical management (ibuprofen, yoga, injected steroids) over any time span longer than a few months. Medicare shells out around $2 billion per year for such back surgeries.

Heartburn surgeries, shown by a large randomized clinical trial to work no better than over-the-counter drugs like Prilosec and Nexium.

Implanted defibrillators, which are literally lifesavers for most people who receive them. But a major recent study in the April 7, 2010, issue of the Journal of the American Medical Association found that 22 percent of Americans who get them don't need them?they don't fit the "evidence-based" profile of patients who would be helped and not hurt. Implanting the device is a major, invasive operation that involves sticking wires into your heart. It's expensive, at an average cost of about $40,000, including the device, hospital charges and the surgeons' pay. It's common, at about 100,000 operations per year. If 22 percent are not needed, they represent an unnecessary expense of about $880 million?nearly $1 billion per year for one common, unnecessary operation that, by the way, puts the patients at risk, as any operation does.

So in these quick examples we have identified wasted costs amounting to something like 4 percent of the $100 billion it is commonly thought it would take to pay for the health care of all uninsured Americans.

But traditionally, as a hospital, these are not your wasted costs. In a fee-for-service system, they are decanted to the payer. The only costs that really matter are your costs per reimbursable item: Can you get reimbursed for this? Can you get your costs of production significantly below your reimbursement? If an extra CT scan, or the whole operation, is not strictly necessary, you're still fine as long as you can get reimbursed for it under the right code.

Saving costs through coordination and avoidance saves money for the customers, for the payers and for the system at large, but if you are fee-for-service, the money they are saving would have been your money. You could have charged for the inefficiencies, the unnecessary scan, the avoidable surgery. Forming an accountable care organization doesn't change that. As long as it is fee-for-service, an ACO is just a way to get back a little of that money you didn't make. You saved costs by driving down your own income.

As we enter a world with more bundled purchasing, value-based purchasing, mini-caps (such as disease-management contracts) and full capitation, all of these deviations from a strict fee-for-service model bring the other ways of cutting costs to the fore.

Making Money by Saving Money

To make money at coordinating care, or through avoiding solution costs and system costs, you have to be at risk for the cost of that size of solution. To make money at bundled payments, you have to be able to control the costs of all parts of the bundle. To make money through cutting solution and system costs, you have to be at risk for the entire solution. If you help a patient avoid a foot amputation by aggressively treating the foot abscesses, or by avoiding abscesses altogether, in a fee-for-service universe, your bottom line just took a huge hit. In a universe in which you are at risk for the health of that patient, because you have a capitated contract for his or her diabetes care or for overall care, your bottom line looks better for every cost you can avoid.

Sometimes this means adding process costs to save the system costs. The Vermont Blueprint for Health is a good example. This project places community health teams in primary care offices. Led by nurses, these teams are charged with tracking chronic patients and offering whatever help they need to manage their situation, as well as coordinating the physicians' offices with community-prevention efforts. The cost, which is borne by the payers, is roughly $350,000 per team per year. Each team can cover about 20,000 people. Do the arithmetic: $17 per patient per year. Result: better health, 22 percent lower cost in inpatient admissions, 36 percent lower cost in emergency visits, 11.6 percent lower costs overall. That's big.

Or the AtlantiCare Special Care Center in Atlantic City, N.J.: This clinic offers special attention, team-based care, and walk-in immediacy to the top 5 percent of health care spenders among the employees of the casinos and of the AtlantiCare Medical System, all for no co-pay, no deductible, even the drugs are free. Result: a 25 percent drop in overall costs for this top-spending 5 percent.

If you are a hospital in a fee-for-service system, those are hits to your bottom line. If you are at risk for those costs, saving them turns into profit.

It's About to Get Really Complicated

This is about to get really complicated for most of us. If you are Kaiser, or the Veterans Administration, or Group Health Cooperative of Puget Sound, fully capitated for most of your users, the calculations are complex, but they have a simple basis: How do you deliver the best possible health and health care at the lowest possible cost? Most of us are not in that situation. Most of us are in a fee-for-service universe, and are not going to become another fully capitated Kaiser any time soon.

But over the next few years we will find ourselves taking up various types of risk-based contracts, coming to count on pay-for-performance bonuses as a major revenue stream, offering bundled products, and competing for "value-based purchasing." Each of these flips some part of the incentives with some part of our users and some part of our suppliers (including physicians, and other providers with whom we join in bundles or any kind of risk-based contracts).

In the face of this vastly more complex price picture, we realize that we are driving systems whose very complexity makes them relatively inflexible. A car company, for instance, can design a cheap-as-dirt car for the Indian market, say, and a range of products from basic pickups to a line of luxury sedans for the U.S. and world market. No problem.

But a health system with some users under risk contracts and others fee-for-service finds those patients intermixed through all their facilities. And the fee-for-service patients from different payers come with different levels and kinds of incentives in their co-pays and deductibles, and different pay-for-performance and value-based purchasing incentives from their plans. It can become difficult to tell whether any particular avoided cost helps you or hurts you.

Redesigning the system to avoid unnecessary costs is hard enough. Designing it to avoid some costs for some patients and not for others is impossible. Kaiser of Northern California has a medically sound, guideline-based program that helps steer patients with knee problems away from unnecessary and unhelpful MRIs, operations and total knee replacements. This saves Kaiser a lot of money and helps the patients improve their knees. If you put such a program in place, would it save you money or just cost you reimbursements? This can become extremely difficult to tell.

We haven't been trained for this. Our training and experience is in a different universe. We are just feeling our way forward here.

So What Is a Hospital Executive Team to Do?

Three core strategies:

First, get fierce about efficiency, the first type of cost. Driving down the process cost of everything you do is a good thing no matter how you make your money. And the improvements in quality that come out of such efficiency efforts will help you with pay-for-performance, with ACO kickbacks if you are aiming for them, with all types of value-based purchasing.

Second, clarify your situation strategically, driving toward simplifying your patient flow and major contracts, so that you can grasp your cost situation easily with the various populations you serve.

Finally, judiciously take on risk for costs you can help control. Then vigorously control those costs, using all the tools available to avoid unnecessary operations and procedures, duplicated tests, and treatments at the wrong level of acuity. In becoming at risk for some populations and some parts of your services, you will have to learn to act as if you are at risk for all of it. You will have to drive your whole system toward greater efficiency and effectiveness, at the same time you are finding various ways to profit from that efficiency and not be driven bankrupt by it.

None of this will be easy, or exactly fun, but it sure will be educational.

Joe Flower is a health care futurist and CEO of The Change Project Inc., and its health care education arm, Imagine What If.� He is also a regular contributor to H&HN Daily and a member of Speakers Express.

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