As noted often, the goal of OMRUM is to reduce the cost of healthcare while maintaining or (better yet) improving quality. However, any time one hears about reducing costs while improving quality, human experience urges caution if not overt doubt. After all, if something could have been made more efficient earlier, why was it not? In the back of one’s mind is the old adage “you get what you pay for”.
Indeed, although many aspects of the healthcare system improve over time (consider the GLP-1 family of diabetes medicines which reduce all-cause mortality), overall, many elements of our system are constrained by inertia. Every once in a while, however, an event occurs which forces convention out the window and (mixing metaphors) opens the door to creativity. In this article, we will discuss one such example which was caused by no less than a hurricane.
Hurricane Helene made landfall in Florida on September 26, 2024 as category 4 hurricane. It worked its way north, ultimately killing approximately 230 Americans in 7 states (sources regarding total deaths vary somewhat). The greatest loss of life and economic disaster occurred in the state of North Carolina (which itself accounted for almost 50% of total related deaths in the US). For the medical community, 1 of the key effects of the hurricane was disrupting production at the Baxter International plant in North Carolina which reportedly accounts for 60% of the intravenous fluids for the United States. In the medical world, intravenous fluids are critical and fundamental. They help to maintain the patients’ so called “volume” which allows oxygen transport via perfusion to all the tissues of the body. They also are useful carriers of many pharmacologic agents such as antibiotics. So, after the shutdown of the Baxter plant, what happened to the hospitals once they exhausted their reserves?
The result was adaptation and creativity. In Becker’s Hospital Review (11/12/2024), author Alexandra Murphy wrote about the Inova Health System in Falls Church, Virginia and its reduction of daily IV fluid use from 2100 bags/day to 1000 bags/day, i.e. it reduced its daily use by over 50%. However, in spite of this reduction, its hospitals and outpatient centers sufficiently improve their efficiency that even outpatient surgeries which had been scheduled before the deficit could proceed as scheduled. Multiple strategies were employed including switching where possible from IV fluid to oral rehydration in select patients, infusing antibiotics and other medications directly into IV fluids in lieu of putting them in their own separate IV fluid bag, revisiting the true need for fluid replenishment in a wider scope of patients, etc. Subspecialties which use more than an average amount of fluids such as urology (e.g., for bladder irrigation) had to think especially carefully about the actual necessity and goals of their fluid choices. This kind of review “in real time” led to a burst of creativity of this 1 resource, fluids.
Now, the economics of this 1 change in the system should be discussed.
According to information obtained by this author, the cost of 1L of sterile isotonic infusional saline (and similar products) hovers at $10/bag. By reducing 1100 bags/day, the Inova Health Systems saves $11,000/day or about $4,000,000/year. The Inova Health Systems comprise 5 hospitals (plus a number of acute care centers and other services). If one takes the liberty of extrapolating this to 6120 hospitals in the U. S., savings would be (rounding up) $5,000,000,000 ($5 billion)/year.
This amazing creativity of resource management was born out of need. IV fluid remains a central element of modern medical care and without it, both death and suffering would increase. However, had this deficit not occurred, no such improvement would be likely. Indeed, if one were to put medical planners in a room and asked them to cut daily IV fluid use by 50% as a theoretical exercise while maintaining full functionality, based on this author’s observation over decades, it is unlikely about this improvement would have occurred on its own.
Again, Becker’s Hospital Review uncovered, in the article referenced above, an inspired way to save money and resources while maintaining quality of care. In contrast, this author will discuss a case he personally managed in which creativity was discouraged.
Some years ago, an indigent patient with severe, poorly controlled diabetes developed a very deep foot infection with frankly purulent drainage draining from his sole. He presented at the emergency room of our hospital and an E.R. physician assigned him to my care. These types of infections are often polymicrobial, i.e. more than one bacterium is involved. 2 antibiotics were selected for him. The patient’s finances were tight (he only had Medicare which pays 80% of the bill, the other 20% had to come out of his own pockets since he had no secondary insurance). Fortunately, the infection could be treated by antibiotics orally instead of intravenously. The oral antibiotics chosen were absorbed into the bloodstream very efficiently and were usually well tolerated. In other words, they could get the job done. Equally important, the oral antibiotics would cost roughly $5/day each whereas the intravenous equivalents would cost roughly $100/day each. Also on the positive side of the ledger would be the fact that nurses can give antibiotics orally much more quickly than by vein. Transition to an outpatient regimen would be easy with oral antibiotics. This author felt he had a triple “win”. However, reality painfully intruded when a case manager contacted me. She said that under Medicare guidelines, the patient could not remain hospitalized if given oral antibiotics regardless of how sick he was (and in the beginning, he was quite sick). Thus, I had to put him back on at least one intravenous antibiotic for no clinical reason (at least I saved the system and the patient $100 daily by giving 1 orally).
EKGs, laboratory tests + blood draws, oxygen supplementation, telemetry, slow infusion of IV fluids to “keep vein open”, injudicious use of IV fluid as described above, food preparation and distribution for NPO (nothing by mouth) patients or discharged patients, excess vital signs for stable patients, intravenous antibiotics when oral antibiotics would do (special care needs to be applied here), useless consultations, low yield imaging studies, and many more practices are frequently unnecessary. Surprisingly, there seem to be few or no studies on good, better, or best treatments to help give guidance to practitioners. If anything, there often seems to be a tendency to “overtreat” patients without regard to actual benefit, necessity, and, sadly, cost.
The initial example within this article of one hospital system improving care while using 50% fewer resources (in this case, IV fluid) gives one hope. Now what would happen if the medical system was only given 50% of current revenues to bring it in alignment with other 1st world nations? If the new administrative entities of an improved health system are responsible for, arbitrarily, groups of 1,000,000 patients (out of a potential 300+ million) at a time and for each patient it is paid $7500 per year (assuming demographics even out), that aliquot of patients will be reimbursed at $7.5 billion yearly. That would move us back into the middle of the top 10 nations. By switching to a system emphasizing prevention and early intervention (what I call upstream treatment) and by giving patients a separate incentive to keep themselves healthy and avoid the need of excess medical resources, costs would go down while quality of care would go up. Every aspect of the medical care system would be reviewed, top to bottom, left to right, front to back. As the system was initiated throughout the country, information on best practices would be shared.
Put in full prospective, the incentives of this system would be fully aligned. That alignment would lead to better care at less cost.