Part of the law is designed to rein in the nation's exploding health care costs by creating hundreds of little experiments that test new ways for hospitals to save money.
One example: At Summa Akron City Hospital in Akron, Ohio, doctors are preparing for a new way of doing business.
Michael Firstenberg, a heart surgeon at the hospital, says there's something a little funny about the way he gets paid. If a patient comes in for a bypass operation, Firstenberg earns a certain amount of money for the hospital.
"However, if that patient that night has to go back for bleeding, then I get paid for that procedure as well," he says. "And everybody's happy because look at all the revenue I'm generating, independent of the quality."
Ken Berkovitz, a cardiologist at the hospital, boils it down to this: "Everybody in the health care system gets rewarded for doing more, rather than rewarded for doing the right thing," he says.
As a result, everything is more expensive. The key question for health care reformers trying to rein in costs is how to create a less expensive system that still provides good care.
Starting on Jan. 1, the federal government, the hospital and some of the doctors there will try a new approach.
Rather than paying for that bypass operation and then paying again for bleeding, Medicare will pay one lump sum upfront to cover the surgery and any complications that occur after surgery. One payment for one operation, plus follow-up; that's it.
If the patient doesn't have problems within 30 days of being discharged from the hospital, the doctors could make even more money than they do today. But if there are lots of problems after surgery, they could lose money.
This shift in how medical providers get paid is changing how things are done at Summa Akron City Hospital in three important ways.
1. Checklists
Surgeons and nurses at the hospital now carry around a sheet of paper listing every simple step they're supposed to perform.
Did the patient get her antibiotics on time? Check.
Did the catheter come out on time? Check.
Research has long shown that documenting simple steps can significantly reduce medical error. Yet hospitals have a hard time implementing checklists, because doctors don't really like them.
"When we came up with this, I kind of felt a little silly for the first few weeks following a sort of checklist or menu," surgeon Eric Espinal says.
But, he concedes, pilots and NASCAR drivers use checklists because they reduce complications. So checklists could be better for patients — and, in the new system, the hospital's bottom line.
2. A Team Mentality
Traditionally, Medicare paid hospitals separately from doctors. But in the experiment at the Akron hospital, Medicare will pay the entire team together, so everyone will share in the savings or costs of each surgery. It's meant to foster a culture of collaboration.
Berkovitz, the cardiologist, says this change hasn't been easy.
"Physicians are a dedicated, strong-willed independent lot, and many of them went into the practice of medicine because traditionally you've been able to be the captain of your ship, and that's not always equated to good care," he says.
3. Helping Patients After They Go Home
Before the ACA, doctors didn't have a financial incentive to prevent patients from being readmitted to the hospital.
Now, once doctors discharge someone, it's in their financial interest to make sure their patients stay healthy even when they're at home. In some cases, that means sending nurses from the hospital to check up on patients once they've gone home.
Eric Espinal asks about one patient. She's 63 years old who is about to be discharged. In the old world, it didn't really matter if that patient came back. The doctors would still get paid. In the new world, once they discharge you, they've got to make sure you stay healthy, Even when you're home. Which, in this patient's case, means having a nurse visit to check her incision, listen to her heart and lungs.
But this patient is refusing home care. She doesn't want anything to do with it. I tried to talk her into it for eight days now. I can't force her to have it.
All of the checklists, teamwork and amped up follow-up care may not help patients like these, some of the most costly to the system. And this gets to an issue that doctors here say Obamacare hasn't addressed. While the law created hundreds of experiments to change the way doctors and hospitals provide their services, it doesn't done nearly as much to change the way patients consume these services.
As hard as it is to change the culture in hospitals, it's even harder to change the culture of us, the patients.
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