“The cobra effect originated at the time of British rule in colonial India. The British government was concerned about the number of venomous cobra snakes. The government therefore offered a reward for every dead snake. Initially this was a successful strategy as large numbers of snakes were killed for the reward. Eventually, however, Indians began to breed cobras for the income. When this was realized the reward was cancelled, but the cobra breeders set the snakes free and the wild cobras consequently multiplied. The apparent solution for the problem made the situation even worse.”
Wow! The cobra effect seems like an ideal term for so many “solutions” in healthcare and health IT. How often do we see well-intentioned initiatives ending up with outcomes that are totally opposite from what was intended? A few that came to mind include:
Long term care hospitals time discharges to maximize payments
CMS pays substantially less when patients are discharged from long-term care hospitals (LTCH) before a diagnosis-related group-specific short-stay threshold. Originally the policy was designed to discourage hospitals from transferring short-term patients to nursing facilities. The reduced payment was based on the assumption that shorter stays cost less and presumably allow CMS to save some money.
In a recent Health Affairs-published study, researchers found that before the policy was implemented, lengths of stays were evenly distributed. After the change was made, discharges were most likely to occur on or immediately after the short-stay threshold.
In other words, a policy that was designed to save money has actually created a strong financial incentive for LTCH hospitals to time patient discharges to maximize reimbursement – and has thus actually increased the cost of care.
Patient satisfaction surveys compromise care and increase costs
New quality-based payment models include incentives for providers that earn high patient satisfaction scores. However, the pursuit of high patient satisfaction scores may lead providers to practice bad medicine by honoring patient requests for unnecessary or harmful treatments.
The goal of outcomes-based payment models is to incent providers for achieving better patient outcomes and lower costs of care. However, compensation plans that weigh too heavily on patient satisfaction scores may actually result in higher costs and worse outcomes.
Insured patients delay treatment because of high out-of-pocket costs
The Affordable Care Act was designed to reduce overall healthcare costs by ensuring that all Americans have affordable health coverage. One expectation was that insured patients would not delay treatment due to costs, which would minimize complications and reduce the need for more expensive medical care, including emergency room care.
A recent Gallup poll suggests that a third of patients – including 25% who are insured – are still delaying treatment because of high out-of-pocket medical costs for office visits and medications. In fact, 75% of emergency room physicians report an increase in ED volumes since the ACA went into effect in January 2014. It may be too early to conclude that increased access to care is driving up healthcare expenditures, though the current trends are troubling.
Meaningful Use hinders innovation
The overarching goal of the Meaningful Use program is to improve patient care through the use of certified EHR technology. In recent years, vendors have been forced to prioritize product development to meet Meaningful Use standards – as well as to address other regulatory requirements for ICD-10, quality reporting, value-based modifiers, and more.
Arguably the overwhelming number of regulations have limited the ability of vendors to enhance their platforms and incorporate features to improve product usability and facilitate better physician workflows and efficiencies. At the same time, many providers are dropping out of the Meaningful Use program because of the expense and difficulty of implementing certified EHRs and conforming to often unwieldy prescribed workflows.
While a few of the mandated initiatives have positively impacted patient care (e-prescribing and integrated orders and results reporting, for example), program critics argue that the industry would have made more progress towards patient care goals if EHR development was prioritized based on provider demands, rather than regulatory requirements.
Our industry has quite a few more cobras still in need of slaying. Kind of makes you wonder what the effect would be if we imported a few mongooses to take on those cobras.
Michelle Ronan Noteboom
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