Jill Burcum: No good deed goes unpunished

Part of a pioneering experiment in health care reform takes place every morning in the Prior Lake basement of Wendell Leno. ¶ After rising, Leno, a 68-year-old retired engineer with congestive heart failure, heads downstairs to the laundry room and steps onto a digital scale next to the washer and dryer. Then he takes a few steps across the hall to his home office, fires up his computer and logs into a secure website at Park Nicollet Health Services. Leno enters his weight and answers five other quick questions to assess his health -- something he can also do by phone if he chooses.

On Wednesday, Leno was feeling good; his answers to questions about swelling, breathlessness and lightheadness were all "no.'' A "yes'' would have triggered a phone call from a Park Nicollet nurse to adjust his medications, check his diet or, if necessary, get Leno in to see his doctor right away.

The idea behind the daily check-ins is to keep heart failure patients healthier and out of the hospital. That's something Leno appreciates -- and that health care policymakers should appreciate, too.

The problem is that the way Medicare's reimbursement system works now, the Park Nicollet program is a money-loser -- in more than one way.

Each year, the St. Louis Park-based health care system has spent about $750,000 for the nurses who monitor daily reports like Leno's and the technology they use to do so. Medicare does not directly reimburse Park Nicollet for these expenses, though some of the pilot project's expenses have been covered by the federal program.

That's hard enough to swallow. Now consider this: Park Nicollet loses an additional $2.6 million a year in forgone hospital revenue as a direct result of the program.

Simply put, Medicare pays for putting patients in the hospital but not for keeping them out. So for every CHF patient in the program who avoids a hospital stay, Park Nicollet loses about $4,600.

Talk about rewarding success with punishment. What medical center grappling with this economy can afford to add a program further weakening its institutional bottom line?

Providers call this the "perverse incentive'' issue. The goal should be to keep patients healthy. Yet providers are only rewarded when patients get sick enough to come into a clinic or need hospital admission.

"We need to do well by doing right,'' said Park Nicollet President and Chief Clinical Officer Dr. David Abelson. "If incentives for doing well are not aligned for doing right, it doesn't work and it's not sustainable to do it right.''

Policymakers, particularly those from Minnesota, get this. The Mayo Clinic's Dr. Denis Cortese has barnstormed the country talking in his hurricane-force style about "paying for value.'' That would mean a payment scheme under which a provider would make more money by keeping patients healthy than by letting them get sick.

The members of Minnesota's congressional delegation have been outstanding advocates for "payment reform" and ending "geographic disparities," Medicare's practice of spending far more on enrollees in states like Texas, Florida and California than it does on Minnesotans -- something that's shown by a frequently cited health care resource, the Dartmouth Atlas.

Taxpayers here should be outraged by those disparities, because it's a big wealth transfer to high-spending areas, and it's money that buys more tests, more MRIs and more office visits but doesn't in general lead to better care.

And that's why it's so frustrating to see slumping support for overhauling the health care system. This week, a Wall Street Journal/NBC News poll found that the number of people who think the president's push for reform is a bad idea rose to 42 percent this month, up from 32 percent in June.

I'm having more than a few moments of déjà vu. I started my career at the Rochester Post-Bulletin, where I wrote about Hillary Rodham Clinton's doomed health care reform and watched a much-needed national discussion founder. Reform died because powerful industry lobbyists spent millions to protect their turf and because jargon-speaking advocates failed to make their case with consumers.

I see the same thing happening again, and it's disheartening, even though I have serious reservations about the current House bill. An overhaul is long overdue. Lost amid the talking heads, the health care terminology and ads now blitzing the airways is an important message: that health care reform is about doing what's right, as Abelson said. Right by patients, right by those left out of the system and right by those who provide the nation's care. The Park Nicollet program is a small step but an important one. The system must be realigned to reward innovation, not punish it.

As Wendell Leno puts it, "That makes sense."

Jill Burcum is a Star Tribune editorial writer and columnist. She is at jburcum@startribune.com.