Our health care system is particularly inefficient and, for some, inaccessible. As for the quality of care, by any measure it is variable at best. Why is it so hard to fix? Why do we pale in relation to most of the industrialized world?
Quoting the venerable Dr. Arnold S. Relman of the New England Journal of Medicine fame, "This problem [the lack of 'practical suggestions'] is a direct result of "the inappropriate organization and perverse economic incentives of a health care Top Ten delivery system that motivates physicians and medical institutions to maximize their income rather than focus on optimal patient care.”
Here follow the Top 10 Challenges to Managing Cost, Quality and Access:
- Value: to enhance it, practitioners must be aligned to minimize Cost while maximizing Quality and Access
- Pay for what works well. Money's the main stimulus: management suffers from always having inadequate provider incentives
- Information technology (IT) It has limitations—live with it! Regardless, understand the difference between data and information.
- Measure and manage; this is the essence of managing care and improving care management; it requires that data be translated into information (If there's no EHR data, use claims data). Use it to build—
- Episodes of care—a fundamental of health care statistical analysis; it is a grouper technique that shows all care over time, regardless of setting and it is case-mix or acuity-adjusted
- Outcomes—the key parameter of what we want to reward; clinical results, strangely, are neither tracked nor optimized in most health care practices
- Case or disease management
- Guidelines/pathways—medical and surgical
- Lack of patient loyalty or engagement—Not knowing who's in your panel or health plan, patient attribution is one of the main stumbling blocks of today's version of managed care--Accountable Care Organizstions and Medical Homes. Other obstacles are job-lock, denying coverage for 'pre-existing conditions,' waiting periods, barriers to access such as heavy co-pays and deductibles, employer-based insurance in general and state border restrictions--what nonsense)
- Defensive medicine is a distraction and it is insidiously costly, despite claims to the contrary
The above "Ten challenges"all speak to the critical management issue of incentive alignment. To elaborate....The commonality of various payment methods such as pay-for-performance (P4P), capitation, bundled payments, withholds/risk pools, and shared savings is that there's to be some degree of financial accountability for medical expenditures.
"To be successful under budget-based payment models, physician practices must be able to accurately predict the future utilization of services by their patient populations and how much it will cost their practices to deliver medical services. Then the key is managing patient care in a way that sticks to the budget."
"Some mix FFS payments with an opportunity to earn additional money if quality and cost metrics are met (shared savings and pay-for-performance [PFP]), others offer only set flat rates for either a package of services (bundled payments), pay a fee each month on a per-member basis (capitation), or set aside some portion of contractual payments, which are paid only if providers meet pre-established goals (withholds and risk pools)."
Lisa Zamosky. "Fractured Income; Emerging reimbursement models pose new risks." Medical Economics. Jun 10, 2012 [Last accessed 7/24/2012]
See also the following two important references
"The Costs of Failure: Economic Consequences of Failure to Enact ... Health Reforms," The Commonwealth Fund Blog.
"A Roadmap to High-value Healthcare Delivery," by Denis A. Cortese, MD and Robert K. Smoldt, MBA where they discuss some of the concepts of and options for improving health care delivery; the authors "zero in on the need to change existing healthcare provider financial incentives toward ‘pay for value’* as a key stepping stone toward high-value healthcare delivery."
* Cortese and Smoldt define "value" as "patient outcomes divided by total cost per patient over time."
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