Leaping Forward in ICU Care and Cost Management

One of the central goals of the Affordable Care Act is to control and cut spending by health care providers, while improving care. In the October issue of Health Policy, Dr. James Gasperino suggests a private-sector alternative to cost-cutting that was developed by an influential purchaser of healthcare, the Leapfrog Group. While Gasperino argues that the Affordable Care Act will put pressure on hospitals to increase their standards of care, he believes that cost-effectiveness will be driven by the private sector.

Gasperino urges health care providers to target the structure and staffing of ICUs as one of the most expensive units of a hospital. ICU beds “account for 30% of the hospital budget…[and] critical care delivery accounts for approximately 1% of the US gross national product.”

His recommendation is based on the work of the Leapfrog Group, which was founded in 1998 by a group of large employers who wanted to develop a measurement system for gauging quality among health care providers. Their mission was to trigger “giant leaps forward” in the areas of safety, quality, and affordability of health care. Many of their goals mirrored the policies later set forth in the Affordable Care Act legislation over a decade later.

The Leapfrog Group proposed a three-prong solution for ICU care, which has been fully adopted by 4% of hospitals and can produce cost savings as high as $13 million in best case scenarios. Their recommendation involves mandatory staffing of “intensivist” physicians who are practitioners with expertise in simultaneous management of multiple organ dysfunction. First, intensivist physicians must work exclusively in the ICU during daytime hours. Second, when not present at the hospital, they must adhere to a 5-minute response rate on telemedicine communication devices 95% of the time. Lastly, they must arrange for ICU patients to have access to a certified physician within 5 minutes.

Primarily staffing ICUs with intensivist doctors can help cut costs in ICUs in key ways. Increasing the hours when intensivist doctors are accessible  and staffing more experienced physicians means new patient issues are more likely to be caught. The combined results create shorter stays in ICUs, which leads to lower patient mortality and an increase in revenue for hospitals.

Despite the simplicity of this proposed solution, there are some barriers to acceptance by hospitals. First, there is the expense of creating a new ICU organizational structure and hiring a new level of physician. Second, there is reluctance by physicians to embrace the cultural change required in doctor-patient relations. However, as federal regulations of critical care continue to build transparency and as stringent budgetary constraints increase, Gasperino argues that it is likely that the private sector will adopt more cost-effective solutions like high-intensity ICU physician staffing.