That was the startling conclusion my cardiologist colleague came to while discussing how to improve care for congestive heart failure patients. He was really saying that the "new drug" - in this case, comprehensive care management - is already known to be so much better that no patient should risk "usual care."
He’s right. Half a dozen good studies have shown the benefits of comprehensive care management, which includes early interventions to prevent exacerbations. For heart failure patients, an exacerbation is a terrifying shortness of breath. Why would any patient accept a random chance of having twice as many terrors!
If we know how to make life better for people with advanced heart failure, why don’t we? One implacable truth underlies the malfunction - Medicare. Quite simply, Medicare’s reimbursements do not pay for some components of comprehensive care management, and groups that provide such services do so as an act of charity.
It is not that good care costs more, but that Medicare excludes key elements of such care - while covering virtually all aspects of current care. One cardiologist told me that his CEO would either laugh or fire him if he asked to spend $100,000 next year (unreimburseable expenses) to reduce the program’s income by half-a-million dollars.
Last January, researchers at the Center to Improve Care of the Dying recruited health care programs for a project to improve care for patients with advanced heart failure. Directors at a few leading cardiology programs told me - in all honesty - that they simply could not afford better care models. Why? Because these models reduce the income of current cardiology programs.
The only way to make good care routine is to change the way America pays for it. In the meantime, vigorous re-design and quality improvement must go hand-in-hand with innovation and real reform in Medicare. This problem may not have a neat and simple solution, but it can be resolved - and you can help!
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