Last December a study by Dr. Arnold Epstein out of the Harvard School of Public Health published a study in the New England Journal of Medicine looking at the relationship between hospital readmission rates for congestive heart failure and rehospitalizations in general. In essence, it found that readmission rates for CHF were linked more strongly— by a large margin—to all-cause readmission rates than other factors. What does this mean? Simply put, much more than known  influencing factors (such as coexisting conditions, lower performance on discharge planning, or greater numbers of cardiovascular specialists), the “culture’ of the local medical practice patterns in terms of the willingness to hospitalize in general drove readmission rates.

More recently, a study in the journal Health Affairs reported that computerized records, intended to reduce redundant and unnecessary medical testing by providing easy access to patients’ prior tests, actually had the opposite effect. Physicians with computerized access to prior imaging ordered tests on 18% of the visits as opposed to 12.9% of the visits when the tracking technology was not available. These results apparently held true even when accounting for variables such as patient demographics, doctor specialty and physician self-referral. The reasons for this were unclear, and the data did not indicate whether the computer systems used clinical decision support that might have influenced ordering patterns.

What seems to be clear, at least to me, is that the same dynamics operate within the health care community as society at large: Medico-legal and financial incentives are hard to overcome. Rules and legislation can only do so much. The current move to realign incentives through various changes in the system, currently ACOs or accountable care organizations, are in their infancy, and my introduction to them shows them to be complex and convoluted, as systems that attempt to realign human nature often are.

Our second president, John Adams said, “Our Constitution was made only for a moral and religious people. It is wholly inadequate to the government of any other.” To paraphrase in more general terms, you can’t legislate morality or good behavior. If the medical community at large and the political forces that help shape it can get beyond the politics and adverse incentives and deal with the coming crisis as such, we will overcome it. It will all come down to four words:

Do the right thing.


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