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Increasingly, the cost of care is unnecessarily dear, rising exponentially while the return on investment is falling precipitously. What can be done about improving the value of health care?
Our health care system is particularly inefficient and, for some it has become unaffordable. As for the quality of care, by any measure it is variable at best. But, why is it so hard to fix our health care system. For a start, it is not a "system"at all and the 'business of medicine' has become 'medical business.'
Dr. Arnold S. Relman of the New England Journal of Medicine noteworthyness, offers: "This problem [the lack of 'practical suggestions'] is a direct result of "the inappropriate organization and perverse economic incentives of a health care delivery system that motivates physicians and medical institutions to maximize their income rather than focus on optimal patient care.”
In my opinion, the Top 10 Challenges to Managing Cost, Quality and Access are:
- 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) limitations—live with it!
- Measure andmanage; this requires that data be translated into information (If there's no EHR data, use claims data). Use it to build—
- Episodes of care—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—it is one of the main stumbling blocks. (A related one is job-lock; move away from 'pre-existing conditions,' waiting periods, heavy co-pays and deductibles, employer-based insurance and state border restrictions)
- Defensive medicineis a distraction and it is insidiously costly, despite claims to the contrary
Though we "embrace advances in health care, we must remember that a number of what were thought to be advances turned out to not be beneficial, or even to be harmful." Nevertheless, a recent Institute of Medicine report gives reform its legs by auguring for "a culture that uses rigorous evidence-based standards to help patients feel better and live longer. To that end, the report describes the following areas of research and development, in other words, a "learning system": increasing the usefulness of information technology (i.e., computational power and connectivity), improving organizational capabilities and management science, and increasing focus on enabling patient-centered care."
To briefly elaborate, the "Components of a Learning Health Care System," listed by Smith fall under three broad categories: Foundational Elements--The digital infrastructure and The data utility; Care Improvement Targets--Clinical decision support, Patient-centered care, Community links, Care continuity and Optomized operations; and Supportive Policy Environment--Financial incentives, Performance transparency and Broad leadership.
Smith M, Cassell G, Ferguson B, Jones C, Redberg R.Institute of Medicine of the National Academies. "Best care at lower cost: the path to continuously learning health care in America" Last accessed September 9, 2012
Comparative-Effectiveness Research (CER) is that evidence--it is basis by which health care can be not only cost-effective, but also efficacious as applied. In brief, CER helps us determine what should and what should not be made available, accessible and covered.
Also referred to as "Patient-Centered Outcomes Research Act of 2009," CER makes information available to help "clinicians and patients choose the options that best fit the individual patient's needs and preferences." The "conduct and synthesis of research comparing the benefits and harms of various interventions and strategies for preventing, diagnosing, treating, and monitoring health conditions in real-world settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision makers about which interventions are most effective for which patients under specific circumstances."
Per the Federal Coordinating Council for Comparative Effectiveness Research, which is established by the Office ofthe Secretary in the Department of Health and Human Services (DHHS)
CER, broadly, is concerned with the methodology of information technology (I.T.), data infrastructure, the translation of data into information and its promulgation (although they would undoubtedly prefer the word, "dissemination," it being less aggressive).
Conway PH, Clancy C. "Comparative-Effectiveness Research — Implications of the Federal Coordinating Council's Report" Published at www.nejm.org June 30, 2009 (10.1056/NEJMp0905631)
The IOM committee also recommended "supporting CER related to patients' decision making, unhealthy behaviors such as smoking, and determining the most effective dissemination methods to ensure translation of CER results into best practices."
Key Priority Areas of Interest
The graph shows 100 primary and 193 secondary research topics by topic with "Health Care Delivery System" being the most prevalent. After that, nearly 1/3 was racial and ethnic disparities, 1/5 was patients' functional limitations and disabilities. Thereafter, in terms of prevalence, were: cardiovascular disease that ranked second as a primary research area [1], geriatrics, psychiatric disorders that ranked third as an area for primary research [2], neurologic disorders [3], pediatrics and cancer [4].
[1] Cardiovascular and peripheral vascular (CV-PVD) diseases were the leading causes of death in the U.S. in 2006. Note: one might consider in this context that heart disease is a co-morbidity where the primary disease or condition is diabetes or obesity, respectively; and both of these are, unfortunately, increasingly more prevalent.
[2] Includes mental health care—venues and locations, provider training, pharmacologic treatments of or for depression and/or suicide consequent to mental disorders.
[3] Incorporates diagnostic imaging and interventions for headaches, multiple sclerosis, epilepsy and dementias including Alzheimer's disease.
[4] Cancer is second to CV-PVD in U.S. deaths and "one of the most costly diseases to treat. [It] is the focus of six recommended primary CER topics, including screening technologies for colorectal and breast cancers and the [appropriate] use of imaging technologies for diagnosing, staging, and monitoring all cancers.
Iglehart, John K. "Prioritizing Comparative-Effectiveness Research -- IOM Recommendations." N Engl J Med .June 30, 2009; pub. Online: 0: NEJMp0904133
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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