A quote today by safety expert John Nance spoke directly to my interests at the intersection of safety, quality, and policy. The new paradigm in healthcare, he said, is “no outcome, no income”.

The path from fee-for-service to value-based reimbursement has been long and often tortuous, and we’ve not yet made a full transition to rewarding health rather than illness.

It is important to be mindful, however, that well-intentioned changes can sometimes have unexpected consequences. A recent paper in Health Affairs showed that a Medicare payment policy change intended to incentivize an appropriate length of stay for patients in long term care hospitals, has likely resulted in gaming of the system. The result: many patients are discharged on the very first day that meets the threshold for full payment.

While this paper didn’t explore the outcomes consequences of this pattern, what’s clear is that a policy designed to align payment… Continue reading →

“If you want to starve a dog, tell two people to feed it” – Dave Mayer

I’m an economist by training, so the tragedy of the commons is a familiar concept, yet somehow I’d never seen the (in retrospect very obvious) connection to teamwork — and by extension to patient care and safety.

The lesson is both simple and profound: accountability for critical tasks must be rigorously defined… and few tasks in health care are not critical.