WASHINGTON - If you pay the mechanic $1,000 to fix your transmission and it breaks again next week, the garage should find and fix the problem for free. So if you get an infection following open-heart surgery because the doctor forgot an antibiotic, why are you charged extra to clear up the wound?
At Geisinger Health System in Pennsylvania, pay a flat fee for bypass surgery and you'll get essentially a 90-day warranty on your heart fix. Complications? The hospital has to eat the cost. It gambled that following a checklist of best practices would help patients recover faster and cost less - and so far, it's winning the bet.
It's a radically different approach to a health care system that even many doctors agree rewards volume of care over quality. Yet around the country are hospitals and health systems like Geisinger that President Barack Obama calls "islands of excellence," places quietly trying innovative changes to improve patient care at below-average prices.
Places like:
• La Crosse, Wis., where astoundingly, nearly 95 percent of senior citizens have living wills to guide end-of-life care, meaning more hospice care and less hospitalization while dying. That has Medicare paying about $18,000 for the last two years of a beneficiary's life here, compared to nearly $64,000 for end-of-life care in Miami, the nation's priciest health market, according to the Dartmouth Atlas of Health Care.
• Cedar Rapids, Iowa, where two competing hospitals worked together to create a community clinic that lowered side effects and hospitalizations of patients who use a risky blood thinner.
• Everett, Wash., where monthly reports compare how doctors prescribe generic drugs or pricier brand-names, and patients get a checkup call when they leave the hospital to make sure they're following up with their regular doctor.
They're different approaches. But they aim to cut overuse of health care - like avoidable hospitalizations, or repeating tests because one doctor didn't send another a copy, or unnecessary visits to specialists.
"Does the public buy the idea that more care is not better? The answer is no. Yet you're doing it," Dr. Donald Berwick of the nonprofit Institute for Healthcare Improvement told a recent meeting of La Crosse and nine other communities that spend about $1,500 less per Medicare patient than the national average but rank well for quality.
It's sobering: The respected Dartmouth Atlas shows that in parts of the country, Medicare pays double or triple the price to treat the similarly ill - yet people in more expensive areas don't get better quality care. By some measures, they fare worse. The differences can't be explained by big cities' higher living costs. Volume of care is the chief driver, says Dr. Elliott Fisher of the Dartmouth Institute for Health Policy. He says 30 percent to 40 percent of hospitalizations alone are avoidable.
Some health systems limit overuse by putting doctors on salary instead of the usual fee-for-service. Fisher says physician teams help, too. Instead of waiting a week for a specialist to run a heart test, the family doctor asks a collaborating cardiologist which test to order and consults with the result.
Then there's Geisinger's approach, called ProvenCare. Surgeons at the Danville, Pa., hospital turned national guidelines for heart bypass into a specific checklist of 40 best practices - like ensuring that antibiotics, blood thinners and other medications are given correctly before and after surgery, and that proper pre-surgery tests are in. Miss a step and the operation's canceled.
At the program's start, 60 percent of patients got every check. Today, all do.
Then came the price test: Patients insured through Geisinger's insurance unit are charged a set price for the surgery and all pre- and postoperative care, that 90-day warranty.
"We were pretty nervous that this could be upsetting an apple cart," says associate chief medical officer Dr. Alfred Casale.
But ProvenCare patients are recovering faster, rehospitalizations for complications have fallen 40 percent - and the hospital and its health plan have saved thousands of dollars, he says.
So Geisinger expanded ProvenCare to half a dozen other areas, from joint replacement to obesity surgery, and is negotiating with other insurers to join.
The lesson: "There were things that would get dropped, and we didn't know that until we started auditing it," says nurse Linda McGrail, joint replacement coordinator.
• Lauran Neergaard covers health and medical issues for The Associated Press in Washington.