The Importance of Health Care Reforms in America

Improving the U.S. health protection requires identifying and addressing its current shortcomings in an effort to achieve higher standards and value without reducing access to necessary care — and making the organization more efficient in the process.. Efforts have been made to improve quality and value through programs such as disease management and HIT, but they have had mixed success because of design flaws or interactions with problems in our health care system. There could be some reform options that would improve quality and value in the U.S. health care system, with the goal of slowing the rate of cost growth.

Care coordination refers to a range of reforms that reorganize primary care and add resources, with the goals of improving preventive care, transitions from one care setting to another, and information exchange as patients navigate the health care system. In particular, care coordination is intended to address not just one but multiple chronic illnesses that often occur together, particularly in patients at high risk for costly complications. Care coordination differs from DM in its focus on primary care. A typical care coordination intervention involves assigning a primary care manager to educate and check on patients between visits, coordinate treatments and record-sharing among each patient’s several doctors, and remind doctors and patients about important, cost-effective treatment steps that need to be taken to improve patient outcomes.

Research shows that care coordination can improve quality and may lower cost, particularly when it is targeted at high-risk groups — including individuals who are low-income, have multiple chronic diseases, and were recently hospitalized. It will be particularly important to examine the research results of programs that combine medical home reforms with other steps to support integrated care, since more integrated health care delivery systems appear to be able to achieve more significant impacts. Reforms like the North Carolina Medicaid-led effort, which is now being extended to other payers, may be particularly informative in this regard. As care coordination programs expand, future evaluations should analyze the cost of these interventions and compare their costs to the savings that result. Future evaluations should also analyze the cost per QALY gained to account for the importance of health improvements. Care coordination reforms may be more likely to succeed if they are coupled with fundamental payment reforms that promote coordination and integration.

An important challenge for the U.S. health system is the lack of evidence regarding (1) the clinical effectiveness of different treatments and health care practices and (2) the impact of payment and other policies that seem to influence practice strategies. Relevant evidence on the effectiveness of many treatment alternatives is limited. There is considerable support for increased investment in comparative effectiveness research (CER) that would generate more evidence on benefits, risks, and potentially costs to support health care decision-making. Standard definition of CER refers to clinical and economic evaluations of different medical interventions compared to alternatives for selected clinical indications and for particular patient populations. This includes comparisons of diagnostic and therapeutic interventions, for example comparing the effects of drug A to the effects of drug B for a given clinical issue or type of patient, as well as alternative approaches to care for particular patients in similar clinical contexts. Other types of evidence on comparative effectiveness may also be very useful for formulating policy. For example, since most of the variations in practice that account for variations in cost do not relate to specific differences in treatments, defining CER more broadly to include comparisons of practice strategies could also provide more direct and useful guidance for influencing those practices.

Reform proposals often focus solely on extending coverage to uninsured Americans, but coverage expansions will be less expensive and more beneficial if they are paired with delivery reforms. Conversely, the effectiveness of delivery reform will be limited if it does not address the substantial underuse of valuable care among the uninsured. Thus, coverage expansions and delivery reforms should be pursued together. Integrated delivery reforms are likely to increase health care quality and reduce cost growth. These improvements would induce some uninsured Americans to purchase coverage and some Americans on Medicaid to switch to private insurance

To change how care is delivered, a critical element of health care reform involves transitioning toward payment systems for providers and benefit systems for patients that directly support better value.

Information technology systems need to enable patient-centered care. Although this seemed to be the premise of EHRs, in reality, most have focused on enhancing billing, revenue, and documentation, rather than closely tracking the health, wellness, outcomes, and cost of individual patients throughout the care continuum. In the healthcare system of the future, the patient-centered EHR has to be readily accessible to all care providers, as well as to the patients themselves; it has to be easy to input and extract data; and it has to use common definitions for data.

Such EHRs should be welcome by hospitalists and should do anything to accomplish in the healthcare system.

Care should be integrated into a smaller number of large delivery systems, instead of a large number of small, “do-it-all” systems. These large systems have to actually work for the good of the patients, integrating their care and not just providing duplicate services in each location. Each center should be able to deliver excellent care in some conditions, not adequate care in all conditions. The more complicated, complex care should be delivered in tertiary care centers, and the more predictable, less heterogeneous care conditions should be addressed in lower-cost, community settings. Integrated systems can direct the right patients to the right location, to enhance both quality and cost.

Reimbursement for services should reflect the actual cost of the service and should be bundled. Many hospitalists are likely already involved in some demonstration projects around bundled payments for care across a continuum. Many CMS demonstration projects have focused on high-volume, predictable conditions (total hip arthroplasty, for instance) or high-volume, less predictable but costly conditions (such as congestive heart failure or COPD). Some large employers also are contracting with high volume hospitals to perform semi-elective procedures such as coronary artery bypass grafting, and sending their employees out of state to these centers of excellence. Most hospitalists are already at least conceptually comfortable with being held accountable for the cost and quality of certain patient types, including reducing unnecessary variation and spending and avoiding preventable complications.

Providers need transparent and readily available information on quality and cost to move the value equation. As we all know, you can’t improve what you don’t measure. Hospitalists need to work collaboratively with their hospital systems to collect and widely report on quality and cost metrics for the patients they serve. These quality metrics should not only focus on those process and outcome measures that must currently be reported (internally or externally); hospitalists should seek out the metrics that really matter to patients, such as achieving functional status (ambulating, eating, being pain free), shortening recovery time (getting back to work, playing with the grandchildren), and sustaining recovery for as long as possible (relapse, readmission, reoperation).

Hospitalists should embrace the transparency of these metrics and encourage attribution of the metrics to individual providers or provider groups. Metric transparency stimulates rapid improvements and fosters goal alignment. Measurement and reporting of cost is absolutely essential in moving the value equation. There should be clarity about products, tests costs, supplies and manpower and should be shared with the patients and families to make them aware about value.

Conclusion

There is a great challenge to accomplish all the above mentioned goals as it will take tremendous leadership and a bit of faith in the end goal. But change is very important as current healthcare spending threatens the American Dream. Hospitalists should cooperate in the achievement of high-value healthcare system.

References

• 1. Curfman GD, Morrissey S, Drazen JM. High-value health care–a sustainable proposition. N Engl J Med. 2013;369:1163-1164.
• 2. Leading health care innovation. Available at: www.hbr.org/special-collections/insight/leading-health-care-innovation. Accessed October 22, 2013.