IV. ELEMENTS OF QUALITY IN A PROVIDER SETTING
Within a provider setting, quality can be scrutinized in a number of functions.
1. Information Management – Any judgement is only as good as the information on which it is based. Healthcare is no exception. Disparities in provision of care can be minimized by carefully managing information. Some of the ways are given below[5]
a. Stratify clinical performance measures according to socioeconomic/ethnic disparities
b. Make information available for public reporting
c. Synchronize data collection efforts
2. Create an alternative for fee for service - The fee-for-service payment system in the United States leads to more care, but fails to create high-quality and efficient care. Some of the alternatives include
a. A new payment model based on a set of severity adjusted evidence-informed case rates (ECR). Risks maybe categorized as [6] –
i. Probability risk (Based on the likelihood of a negative event not controlled by the provider). Example: genetic makeup of the patient. This will be the financial responsibility of the insurer
ii. Technical risk (Providers responsibility). This includes readmissions. One of five Medicare beneficiaries discharged from the hospital is readmitted within 30 days, and half of non-surgical patients are readmitted to the hospital without having seen an outpatient doctor in follow-up [8].
3. Eliminate process waste through Lean management initiatives – The core idea is to replace waste with value. Value is defined as the capability to deliver exactly the (customized) product or service a customer wants with minimal time between the moment the customer asks for that product or service and the actual delivery at an appropriate price [11]. The key here is that value must be defined from a consumer perspective.
In sum, all quality endeavours point to incremental and sustained integration between interfacing entities in the healthcare provider space. Let us talk about the each of them in brief.
V. INFORMATION MANAGEMENT
Information has to be managed from creation to archival such that it is accurate, contextually relevant, and available in a timely manner. Only such information is of value. Example - Clinical performance measure is a subtype of quality measure and captures data on access, outcome, patient experience, process and structure during episodes of care. Non clinical data such as master patient index are also to be managed with care.
Pros
1. Quality measures are used for process improvement, higher accountability and research
2. Avoid repeat therapy. This is especially valuable in case of indigent care and charity care
Cons
1. Even though these data are collected by institutions they are largely for private use. Public sharing of such information is neither mandated nor voluntarily offered. The reason is that this genre of information is considered to be of competitive advantage and fiercely protected by the providers.
2. The physicians perceive that every patient with associated medical conditions is unique. The nature of relationship between physician and the hospitals are contractual and there are not enough incentives for the physicians to devote additional time towards such initiatives.
3. Data collection puts additional strain on human and technological resources. Smaller institutions may not have the resources to bring in these practices
VI. PAYMENT REFORM – BUNDLED PAYMENT
At the very heart of integrated care is the bundled payment. It would mean more collaborative care. Bundled payments provide a single payment to both hospitals and physicians thereby creating the need for synergy between hospitals and physicians.
Pros
1. 180 degree turnaround on the current mode of payment. Hospitals and physicians, currently paid on separate fee schedules, would now have financial incentives to collaborate and work together.
2. Is likely to bring down the number of readmission through shared accountability
3. Will pave the way for unified billing
Cons
1. Likely to cause a disruption in the current system. Adoption will be slow and recalcitrant. Needs the cultural change of “putting patients first”.
2. Will encourage more hospitals to have physicians on salary and will be resisted by the older generation of physician community. Smaller physician(s) or groups will eventually be driven to join larger groups
3. It is possible that short term cost cutting initiatives will result is degrading the value offered to patients resulting in delayed access.
The Medicare Payment Advisory Commission has created a policy path to transition to bundled payments. This includes [13] [14]:
1. Phasing-in various aspects of bundled payments first, to providers who are fairly well integrated, and then slowly encouraging other providers to adopt the payments.
2. Capture and share service and resource usage data
3. Adjust payment based on resource use over an episode of care on select conditions (acute care)
VII. LEAN MANAGEMENT
Lean is an innovative philosophy that can be applied to the health delivery processes to sustain operational quality and address socio technical issues. Operationally Lean management provides better organization, increased productivity and reduced waste – all encouraging process improvement by reducing process variation. The technical risks or artificial variability has a lot to do with the efficiency of health delivery and often contributes to “waste” in the system.
In the healthcare world, there are multiple definitions to value. The administration may have interest in the quality adjusted life year value while the physician may concern himself only with the clinical value. According to Lean the value is an inherent property of the system at work bounded by design and not by the individual talent or will. Lean initiatives are at the heart of Integrated Care Programs or Pathways.
Pros
1. Artificial variability related to controllable factors is minimized in the design and management of healthcare systems. One example of artificial variability is medication management.
2. By balancing operational and socio-technical aspects of Lean, exponential improvements are possible. Value stream analysis is a good way to make sure the process and the people performing the process are aligned.
3. Will naturally help the evolution of integrated pathways for care and administration
Cons
1. Natural variability of the process is caused by the fact that no two patients are identical. This has to be recognized while applying Lean management in healthcare.
2. The practice of Lean thinking could negatively impact the population of healthcare workers. WHO data suggests there are about 6-7 million healthcare workers in the US including, pharmacists, midwifes, physicians, nurses, lab workers, management and support workers. This can be pre-empted by fostering a culture of Lean and managing change responsibly.
3. Will need information standardization and sharing
4. Healthcare professional are trained to be fiercely independent and need to be aligned to the merits of collaborative care and working in an interdependent environment.
5. Qualified leaders and managers that foster creation of an environment of collaboration are scarce. This manpower is vital for success.
6. Lean is not a piece meal approach but system wide. So it requires top level endorsement. The senior management must trust Lean to increase value for the patient and drive profits.
Socio-technical aspects of Lean - Lean interventions have the potential to make jobs simple and accurately repeatable. Simple jobs may not be found to be challenging enough for highly trained physicians. Lean interventions may also give rise to jobs that require more thinking, planning and responsibility which may be resisted by workers depending on the nature of employer-employee relationship.
VIII. POLITICS AND POLICY OF REFORM – NOW AND ROAD AHEAD
A Commonwealth Fund survey shows the following [19]
1. 70% of the opinion leaders think that the fundamental payment reform is at the root of meaningful reform
2. 62% of the leaders feel that fostering integrated health delivery systems is the most effective way to bring down healthcare costs
The HITECH act is a great example of what the government can do to empower the health delivery systems to build quality in their domain. In the current reform drafts, the president has set a target of 155 billion in costs saving from the hospitals that translates roughly to about 2.6 million per year per hospital in cost savings. Interestingly the hospitals CEOs are upbeat on achieving this target using a variety of methods including Lean [18].
From 1912 till today there have been several attempts at tactical health reforms. These have not been strategic successes because they have been at odds with the core interest and benefits of the Americans at large. In my view, a high level roadmap could be as follows:
1. Bring on payment reform through bundled payments. Government must help providers to structure themselves to adopt the new payment mechanism. Hospitals will play along if they are incentivized as with HITECH Act to work in a collaborative model. It will bring up new models of nurses-physician-hospital/group engagement.
2. Create incentives to adopt integrated delivery systems with targets to reduce adjusted cost per episode of care, year on year. The government will struggle to make this objective and set up outcomes reporting mechanism.
3. Create health exchange to share information from both insurance and provider. It will have ample support from consumers and insurers, who will begin to enjoy more choices among providers. Hospitals will drag their feet because it would means sharing of competitive information. They will come along as they see its merits in providing indigent care. The government will have the opportunity to conduct evidence based research using this data to arrive at setting national levels of care and reimbursement guidelines.
Some of the factors that can aid the reform can be
• Continued tort reform like putting a limit of the economic damages
• Decrease “morale hazard” by getting the consumers to have a stake in keeping the cost of healthcare spending down (perhaps through health savings accounts)
• Putting a cap on the administrative costs of insurers.
The steps above is likely to result in reduction of redundant therapy (repeat imaging services), address over-reimbursements issues, expand the scope of practice for non physicians, reduce medical errors and create incentives for preventive medicine. Subsequent to the quality based reform, the government can proceed with legislations to increase coverage and introduce public option. For now moving the reform on the quality angle allows us to keep the value of healthcare proportional to the cost – a proposition that will resonate with the most Americans.
IX. REFERENCE
[1] Socialism vs. Capitalism: Which is the Moral System? On Principle, v1n3 October 1993 by: C. Bradley Thompson. [Available] http://www.ashbrook.org/publicat/onprin/v1n3/thompson.html
[2] Public Health Then and Now January 2003, Vol. 93, No. 1 | American Journal of Public Health by: Beatrix Hoffman, PhD [Available] http://www.ajph.org/cgi/content/abstract/93/1/75
[3] About that health-reform cost study Tuesday, October 20, 2009: by Karen Ignagni. [Available] http://www.washingtonpost.com/wp-dyn/content/article/2009/10/19/AR2009101902936.html
[4] Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA. 2000 May 17;283(19):2579-84: by Fiscella K, Franks P, Gold MR, Clancy CM. [Available] http://www.ncbi.nlm.nih.gov/pubmed/10815125
[5] Lean and Collaborative care at Thedacare. [Available] http://www.leanblog.org/2009/10/lean-collaborative-care-at-thedacare.html
[6] Francois de Brantes: A New Payment Model for the U.S. [Available] http://www.commonwealthfund.org/Topics/Health-Care-Quality.aspx
[7] The Nation’s Health Dollar, Calendar Year 2007: Where it Went? [Available] http://www.cms.hhs.gov/NationalHealthExpendData/downloads/PieChartSourcesExpenditures2007.pdf
[8] New Study: 20 Percent of Hospitalized Medicare Patients Readmitted To Hospital Within 30 Days; Half Rehospitalized Without Seeing a Doctor After Discharge. [Available] http://www.commonwealthfund.org/Content/News/News-Releases/2009/New-Study-20-Percent-of-Hospitalized-Medicare-Patients-Readmitted-To-Hospital-Within-30-Days.aspx
[9] Change the Microenvironment: Delivery System Reform Essential to Controlling Costs. [Available] http://www.commonwealthfund.org/Content/Publications/Commentaries/2009/Apr/Change-the-Microenvironment.aspx
[10] State wise per capita income. [Available] http://www.bea.gov/newsreleases/regional/spi/2009/pdf/spi1009pc_fax.pdf
[11] Application of lean thinking to health care: Issues and observations [Available]: International Journal for Quality in Health Care 2009; Volume 21, Number 5: pp. 341–347 Advance Access Publication: 19 August 2009
[12] Using Measures. [Available] http://www.qualitymeasures.ahrq.gov/resources/measure_use.aspx
[13] Bundled Payment. [Available] http://www.andrew.cmu.edu/user/aspark/policyarea.html
[14] MedPac [Available] http://www.medpac.gov/transcripts/0408_pathtobundling_public_pres.pdf
[15] WHO [Available] http://apps.who.int/globalatlas/dataQuery/reportData.asp?rptType=3
[16] Wikipedia QALY [Available] http://en.wikipedia.org/wiki/Quality-adjusted_life_year
[17] Going Lean in Health Care. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2005. [Available] http://www.IHI.org
[18] Hospital CEOs: Reform savings goals doable with lean, Six Sigma, Toyota methods. [Available]
http://www.fiercehealthfinance.com/story/hospital-ceos-reform-savings-goals-doable-lean-six-sigma-toyota-methods/2009-09-10
[19] Commonwealth Fund. Commonwealth Fund Health Care Opinion Leaders Survey, April 2009. HCOL_Slowing_Growth_of_HC_Costs__Chart_Pack_Slides_04242009_PF [Available] www.commonwealthfund.org
[20] AEI Outlook Series: The Politics and Principles of Health Care Reform by Joseph Antos [Available] http://www.aei.org/docLib/11-HPO-Antos-Sept-09-g.pdf
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