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The relationship between physicians and hospitals has always been a dynamic and symbiotic one. The development of modern medicine focused on the treatment of acute illness – infections, trauma, heart attacks, surgery. Tremendous progress has been made in each of these areas. As a result, life expectancy has increased, and the medical needs of the population have shifted from the acute episodes of illness, to management of chronic disease processes. Atherosclerotic cardiovascular disease, auto-inflammatory disease, and even malignancy increasingly require a coordinated and multi-faceted approach that encompasses prevention, integrated disease management, and only rare or episodic hospitalization.Concurrent with these trends, the financial exigencies of the current approach to medical care threaten the very economic viability of our society. The United States spends twice as much as any other nation on health care, but ranks well below most western nations in infant mortality and preventable death, as well as many other parameters of societal health. Reimbursement has largely been episode-based. Whether that episode represents a visit to the doctor’s office or a procedure, physicians and hospitals are paid for what they do. From the perspective of economics, such an approach is intrinsically logical – professional expertise is exerted, resources are consumed, and reimbursement should be commensurate with the complexity and sophistication of the service provided. Implicit in such an approach is the incentive to perform an increasing number and complexity of services in order to maximize reimbursement. Such is a free enterprise approach to commerce, with the market dictating the limits of appropriate activity. However, in health care, several factors have made this approach unfeasible. First, the services being provided cannot be reasonably perceived as voluntary. In other words, whether or not one chooses to purchase an iPhone 5 will depend upon ones needs, resources, and alternatives. However, if one has a life-threatening medical condition, one does not have the “luxury” of elective decision-making. Secondly, quality is only one component of value in the general economy, whereas in medicine, it is an imperative. I may choose to buy a simple car which gets me to and from work, or I may choose to buy a luxury-mobile that has elegant features based upon my financial situation and tastes. However, all medical care should seek to achieve the highest standards of quality, regardless of the patient’s ability to pay. Thirdly, both doctors and patients are removed from the economic impact of their medical decisions. Third party payers are left to deal with the financial risk of medical decision-making. If my physician recommends that I undergo coronary artery bypass surgery, informed consent does not include a comparative financial analysis of the cost of CABG vs. that of percutaneous coronary intervention vs. that of medical therapy – the sort of dollars and cents information which might inform our everyday decisions regarding which supermarket to shop at and what items to buy. Lastly, there is a growing societal consensus that health care itself is a right of every citizen, which therefore shifts the burden even further from the “consumer” (patient) or entrepreneur (doctor/hospital) to the government to provide the financial foundation for healthcare.
What is emerging is a new paradigm for modeling the financial aspects of medical care, basically focusing on outcome rather than effort. Payers are increasingly interested in developing metrics with which the quality of care can be assessed. Value then becomes a function of quality divided by expense, and decisions can then be made based on value. If the incremental information or clinical benefit gained from a sophisticated test or procedure pales in comparison to its cost, then perhaps it does not make sense to pay for it. That which is newest is not necessarily best – perhaps the clear light of evidence should be used to help determine the wisest approach to patient care.
These forces – changing patterns of disease management and evolving models of reimbursement, are radically altering the relationship between physicians and hospitals. Traditionally, for the physician, the hospital represented the ultimate resource for care of his sickest patients, while, for the hospital, the physician represented an essential source of patients to fulfill its mission. Increasingly, however, it is being realized that the hospital is not the pinnacle of care, but rather needs to redefine its role in a more integrated system of care. Similarly, dropping reimbursement in face of increasingly costly demands for information infrastructure that can support documentation of outcomes have compelled physicians to explore joining forces with the hospitals rather than viewing themselves as independent entities. Hopefully, the ultimate result will be a more integrated health care system which is capable of determining, modeling and promoting best practices in a more efficient manner. It is in this complex integrative milieu that institutions such as the Florida Heart Research Institute, by virtue of its independent nature, distinguish themselves as a critical resource to patients, physicians and hospitals in the generation and dissemination of evidence-based medical information.
