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It's disheartening; the cure for the ills of U.S. health care lies within our grasp, yet it eludes us. We cannot answer basic questions–What works?  What we are paying for? Are we getting what we need?  Are we getting the right care at the right time and place?

QI and UM: Strange bedfellows, but both need data to communicate

We pale in comparison to many other countries (even some third-world nations). Speaking as a former physician executive, a job that often put me in charge of quality improvement and its strange bedfellow—utilization management, I'd like to present tried and true ways to reduce poor quality and improve cost-effectiveness in health care.  But, first, we must remember that data ain't information; our great data analytics,* feedback loops and algorithms will "only get us so far. If we have poor underlying data, the analyses may end up misleading us. We must be careful for problems of data incompleteness and incorrectness."

"There are all sorts of reasons for inadequate data in EHR systems. Probably the main one is that those who enter data, i.e., physicians and other clinicians, are usually doing so for reasons other than data analysis....I also know of many clinicians whose enthusiasm for entering correct and complete data is tempered by their view of the entry of it as a data black hole.... [I.E.,] they enter data in but never derive out its benefits. I like to think that most clinicians would relish the opportunity to look at aggregate views of their patients in their practices and/or be able to identify patients who are outliers in one measure or another. Yet a common complaint I hear from clinicians is that data capture priorities are more driven by the hospital or clinic trying to maximize their reimbursement than to aid clinicians in providing better patient care."

* Health Care Analytics

Dell's "Healthcare Analytics: The Way Forward," Nov. 2013 is on point, especially its "Healthcare Analytics Adoption Model," which is as follows [modified]: Fundamental or Big Data as a Foundation; then Basic Business Intelligence Reporting; Performance Management; Predictive Analytics Results; Prescriptive Type of Recommendations

Sanders, D.. Cultural Principles and Patterns in Healthcare Analytics. 9/27/2012 Source: Healthsystemcio.com 9/27/2012

Of course analytics, the translation of data into information, closing the feedback loop and otherwise communicating is the critical challenge in this, the Age of Information Technology in Healthcare.

If we only had the transformative data, information and follow through. Here's a very recent JAMA piece that speaks to this.

The management parameters of cost, quality and access are like the three-legged stool; shorten one or two legs and the whole managerial effort will have less value, if not fail all together.  To keep everything in balance and synergistically working well, we need to know what works and what does not. Dr. Blumenthal gives us a timely healthcare information technology (HIT) solution—liberate "data from electronic repositories so that the information can follow patients through the health care system. Although some technical improvements in electronic records will be necessary for health information exchange, equally important will be payment reforms that reward providers for improving the quality and cost of care. Only then will providers incur the expense and disruption required to effectively exchange health information with other institutions that are often local competitors.”

David Blumenthal, MD, MPP, “Better Health Care A Way Forward.” JAMA April 5, 2016 Volume 315, Number 13 :1333-1334

 


The Seduction of Big Data

Dr Mukherjee: " I don't have a problem with big data. I don't believe or disbelieve in [it; rather] What is relevant is: Are we using intelligence to interpret big data? There is a seduction to big data where a lack of intelligence can show. I'll give you the classic, historical example—a monk [Mendel], who had no experience in statistics, for the most part, who crossed two peas, the smallest of small data—and found that, in fact, things don't behave that way. You cross a short plant and a tall plant; you don't get a bell-shaped curve. You get a short plant. It's very discrete. You cross a yellow pea and a green pea, and you don't get an intermediate color pea. You get only one pea. The point is that there is a seduction to big data without smart interpretations of data.…. if you don't use intelligence to interpret big data, then that big data produces nonsense. It produces more big data. And the job of big data is not to produce more big data. It is to produce wisdom, knowledge, and truths."

 "Emperor's Mukherjee on the Three Laws of Medicine.” Medscape One-on-One   http://www.medscape.com/ Oct. 12, 2015  

Ferranti, J. M. "Bridging the gap: leveraging business intelligence tools in support of patient safety and financial effectiveness." Journal of the American Medical Informatics Association, 2010 17(2), 136-143.

_____________________________________________________

"Faced with making decisions about current software tools or purchases considerations, I would be asking vendors about data quality and analytics capability. Think of the amount of time staff spends inputting critical information that directly impacts clinical decisions and reimbursement. That time is valuable and the output essential."

Airbags and Analytics


Putting a square peg into a round hole'

Another challenge for the clinician and support staff is their having to stare at a computer, rather than engage the patient in conversation.  This is made worse from having to go from a loose, impressionistic scribbled note to having to abide by the finding of and constraints from structured data, which is, of course, designed to facilitate data aggregation and analysis.

'Closing the Feedback Loop'--an Essential of Communication

Thomas Goetz of Wired Magazine, in "How can patients make better healthcare decisions?" says to close the feedback loop,* be cognizant of the following four basic questions that a patient may want to ask:

  1. Can I have my information?  [See "Extending Simulation Learning" below]
  2. What does this mean?
  3. Options?
  4. What's next?

* Feedback Loop: A) Personalized Information; B) Realization; C) Choices (Options); D) Clear Point of Action

http://www.tedmed.com/talks/show?id=7053&videoId=6653&ref=about-this-talk


"Extending Simulation Learning Experiences to Patients With Chronic Health Conditions" 

Quote [This JAMA article was published online December 16, 2013; it is free to the public]

As articulated by the Institute of Medicine and reinforced by the recent health reform law, the United States is fostering a deliberate shift toward a more population-based approach to promoting health. Juxtaposed with this shift is the increasing number of persons in the United States with multiple chronic conditions. Thus, the opportunity has never been better and the demand has never been greater to identify and promote a key element of population-based health: supporting individuals and their family caregivers in the self-management of chronic health conditions.

Patients and their family caregivers frequently struggle to understand how to care for chronic health conditions. Inadequate support for self-care in turn leads to poor health outcomes, rehospitalization, and subsequent higher health care expenditures. [ref 1] In this context, patients are sometimes labeled as being “noncompliant.” This label implies that patients willfully elected to ignore clinicians’ advice and the accompanying care plan prepared for them and instead chose a different path or chose not to attend to their condition. Alternatively, the patient may not have had a chance to successfully assimilate his or her care plan. The information may not have been presented in a manner that the patient could understand, or the instructions may not have been feasible to implement in the patient’s home environment. In the absence of any type of feedback loop, health care professionals usually are unaware of where the breakdown occurs.

A recent study conducted by AARP and the United Hospital Fund revealed the significant contributions family caregivers make to managing their loved ones’ chronic health conditions and offered a strong case for the importance of supporting their essential role in health care delivery.[ref 2] Among the 1677 family caregivers participating in this survey, 46% reported performing medical tasks, nursing tasks, or both; 78% reported managing medications; and 53% reported serving as care coordinators. Despite the high prevalence with which family caregivers perform these functions, they described receiving little assistance or training from health care professionals.[ref 2]

In preparing health care professionals to manage acute and chronic health conditions, simulation experiences are recognized as “the most prominent innovation in medical education over the past 15 years” and “a keystone of health profession education and patient safety.”[ref3] If there is such consensus on the effectiveness of simulation, why not consider offering this learning approach to patients?

In practice, many physicians have come to recognize the weak link between providing patients with educational materials or care instructions and realizing the desired health behaviors. Care plans are, admittedly, the clinician’s best guess for what might benefit patients and what seems feasible. Using a simulation experience to test a care plan before a patient and family caregiver leave a facility could help physicians identify obstacles (such as visual impairment, low health literacy,* transient or progressive cognitive impairment, and low self-efficacy) and adjust the care plan accordingly.[ref 3]

** Davis TC, et al (2006) "Literacy and misunderstanding prescription drug labels." J Gen Intern Med; 21: 847-851.

* What Is Teach-back?  "Teach-back: A Health Literacy Tool to Ensure Patient Understanding; perhaps the best way to achieve health literacy" [Iowa] Health Systems

 Always Use Teach-back! Training Toolkit  [Updated April 20, 2016]

  • A way to make sure you—the health care provider—explained information clearly; it is not a test or quiz of patients.
  • Asking a patient (or family member) to explain—in their own words—what they need to know or do, in a caring way.
  • A way to check for understanding and, if needed, re-explain and check again.
  • A research-based health literacy intervention that promotes adherence, quality, and patient safety.

Click here for Toolkit Background and Purpose (VIDEO); and/or "10 Elements of Competence for Using Teach-back Effectively" (PDF).

The discussions on this website are about getting the right care at the right time and place. Join our wide ranging discussions, including the many aspects of care, equity in access, unwarranted variation, standards, efficacy, etc., and help us figure out how to best align incentives and how best to reform our system.

Teaching Effectively

By Larrie Greenberg, M.D., visiting preofessor, Westchester Medical Center, 12/13/2015l with permission
Senior consultant, Medical Education
Office of Medical Education
Clinical Professor, Pediatrics

The simulation approach amplifies the distinction between teaching (traditional patient education) and coaching (promoting skill transfer).[ref 4] The former emphasizes information transfer, whereas the latter involves learning by doing through practice, rehearsal, and role playing. An analogy can be made with a largely successful model for public safety: driver’s education. In most cases, the first stage of driver’s education involves a classroom experience that conveys the rules of the road and a primer on safe driving practices. However, this first stage is necessary but not sufficient for producing competent drivers. The informational session is augmented by a practical experience that involves time behind the wheel supervised by an instructor. This education helps the new driver move from the back seat to the passenger seat, whereas simulation or skill transfer is needed to move the new driver from the passenger seat to driver’s seat.

Several examples illustrate proof of concept for the feasibility and value of offering patients and their family caregivers simulation experiences. For instance, the North Mississippi Health System has pioneered an in-hospital simulation experience for patients with heart failure known as “self-care college.”[ref 5] Rio Rancho Center, a skilled nursing facility in New Mexico, has implemented a program called “return demonstration,” in which a nurse or therapist instructs patients or family caregivers on an aspect of care and the patients are then asked to perform the activity in the presence of the instructor to show that they can perform the task. Simulation in a rehabilitation context has been deeply rooted in the practice of occupational therapy for decades, and patients scheduled to undergo elective knee or hip replacements are encouraged to participate in “prehab,” during which they are given the opportunity to become accustomed to assistive modalities and therapy techniques prior to undergoing the respective procedures, while their minds are free of medications that might impair learning. Simulation to promote skill transfer is the core underlying principle of the evidence-based Care Transitions Intervention that has been widely disseminated. [ref 6]

Implementing a simulation experience for patients poses a number of challenges. First, designing a program that meets the needs of a relatively homogeneous class of medical students is simpler than preparing an approach for more diverse populations of individuals with multiple chronic illnesses attached to a patient-centered medical home or attributed to an accountable care organization. Second, a simulation experience in a health care setting can approximate, but not reproduce, the actual conditions an individual may face on returning to the home environment.

Third, finding dedicated space in a hospital, skilled nursing facility, or patient-centered medical home for this activity could prove difficult. However, implementing a simulation experience for patients may not require audiovisual recording equipment or space having the same degree of sophistication as that needed when using simulation to train health professionals. Fourth, health care professionals may understandably resist offering patients a simulation experience because of lack of time. As a starting point, the time spent offering relatively ineffective patient education could be reallocated for simulation, and additional time may be recouped from the duplication of care that plagues health delivery, including the completion of redundant assessments and care plans, multiple rounds of medication reconciliation, and overlapping posthospital follow-up telephone calls.

Fifth, health care professionals may oppose simulation on the grounds that it is not recognized or compensated. The National Committee for Quality Assurance explicitly requires support for self-care in its criteria for patient-centered medical home accreditation. [ref 7] Effective January 2013, Medicare offers billing codes to ambulatory practices for management of posthospital transitional care; these codes reward support for self-care, among other actions. [ref 8] Scores on the hospital patient care experience tool, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), are incorporated into determining financial reward or penalty under the value-based purchasing program. The HCAHPS tool includes items that address the extent to which patients feel prepared for self-care following hospital discharge.

Across health care professions and institutions, simulation has become the gold standard for training health care professionals to manage health conditions. Perhaps now is the ideal time to ask: Should patients not learn about managing chronic health conditions the same way?"

Author: Eric A. Coleman, MD, MPH, Department of Medicine, University of Colorado, Denver, Anschutz Medical Campus, 13199 E Montview Blvd, Ste 400, Aurora, CO 80045-7201 (eric.coleman@ucdenver.edu). Posted, Dec 16, 2013. doi:10.1001/jama.2013.283057.


Caregivers may want to explore supportive or assistance services and caring professionals such as:

  • Adult day services–Comprehensive assistance packages that may include "transportation, nursing care, meals, personal care (such as help with bathing or toilet use), social opportunities, and/or rehabilitative activities.

  • Certified nurse's or home health aides who can help with activities of daily living (ADL) such as "bathing, dressing, and personal care. Keep in mind that they do not do much housekeeping, if at all and they are not nurses, so they can’t give  meds.  Along these lines, there may be respite care worker, hired companions or homemakers—for example, "a college student who lives in a home and provides help in exchange for rent."

  • Meal programs like the "Meals on Wheels Association of America (703-548-5558, or www.mowaa.org) or the federally funded Eating Together Program, which offers lunch and companionship at community centers. Senior centers, community groups, or religious organizations may have similar services."

  • Case managers. "Some hospitals and health insurance plans assign case managers to oversee and coordinate health care. Case managers are often registered nurses or social workers. They help coordinate services, keep tabs on a patient’s progress, and communicate with the patient, caregiver, family, clinicians, and key departments, such as billing."

  • Nurses. "Nurses offer skilled nursing care, such as inserting intravenous lines, cleaning wounds, and changing bandages. They can also administer medications."

  • Physical, occupational, or speech/swallowing therapists.

  • "Transportation services. Some communities offer free or low-cost transportation to medical appointments for seniors or people who are disabled. Other potential sources of free or low-cost transportation help are religious and community organizations, such as churches or synagogues, councils on aging, and senior centers.

  • Improving Access to Home Care

Schimpff, SC. [former CEO of the University of Maryland Medical Center.] "Time for payment models to stop discriminating against in-home care." Medical Economics Nov. 18, 2016


The United Way (www.unitedway.org) and other national organizations may be able to refer you to services in your community, useful information, and assistance. For example, the Alzheimer’s Association (www.alz.org) offers a 24-hour help line (800-272-3900) and support groups throughout the country. Some of its chapters also offer training programs, assistance with coordinating care, and other services.

Another good resource is a website sponsored by the National Health Information Center:www.healthfinder.gov. It can help you locate resources in your area. A local agency on aging, geriatric care manager, hospital case manager, or social worker can also advise you about local services and may be able to suggest ways to cover the costs.

Source: Harvard Medical School's HEALTHbeat's "Attention caregivers: Making use of helpful services." For more on developing plans and effective strategies for the hard work of caregiving, see the Caregiver’s Handbook."


The promise and limitations of current data entry systems

"An excellent example of the promise but limitations of current data entry systems has been well-documented by Parsons, et al. [8].  They found in a wide sample of primary care EHRs in New York City that the accuracy of data for measuring breast cancer screening quality measures was highly variable due to differing practices in documentation, workflow, and related factors. While some physicians had the quality of their care measured accurately, for many others it was underestimated due to data limitations and not the care they provided.

I cannot claim to have easy answers to this grand challenge, but two related aspects of it sit right before us:

  1. We need to find better and faster ways for clinicians to enter data into the EHR that allow data whose quality is good enough to be re-used for other purposes, such as research, quality measurement and improvement, and public health.
  2. We must reward clinicians for their efforts in entering high-quality data. We must allow them to see aggregate views of patients in their practices and be able to identify outliers. We must also engage them in research, quality improvement, and other system uses of their data.

In short, the concept of “garbage in, garbage out” still remains a problem for computers and information technology nearly a half-century after it was coined. In healthcare, we must give clinicians the best tools and incentives for them to participate in the learning healthcare system. For informatics, the problem of data entry is a grand challenge every bit as important as how to make use of its growing quantity, since the knowledge derived from that data will only be as good as the quality of what is input."

William Hersh, MD, Professor and Chair, OHSU Blog: Informatics Professor  "Data Entry: An Under-Discussed Grand Challenge for Informatics."   This article post first appeared on The Informatics Professor on August 26, 2012.

[Reference 8, therein.]   Parsons, A., McCullough, C., et al. (2012). “Validity of electronic health record-derived quality measurement for performance monitoring.”  Journal of the American Medical Informatics Association, 19: 604-609.


See: Norbert Goldfield and Richard Fuller. 'Transparency of healthcare prices and quality of care: The caboose is at the station waiting…" Posted on August 21, 2015 by   Today’s value-based care models require a different kind of measure. Learn which will lead to improved patient outcomes.

Information Silos; taking a New Systems Approach

"More basic than measurement, there is a need for a 'systems approach' that better integrates clinical care systems with medical educational systems, and provides longitudinal tracking of both learners and patients.

We suggest a concerted effort to better integrate medical education systems across the longitudinal spectrum of education (from student to practitioner), and to integrate these within clinical care systems. This has been championed at the Kimmel Medical College of Thomas Jefferson University, Philadelphia, and the Hebert School of Medicine at the Uniformed Services University, Bethesda.7,8 These centers have established longitudinal tracking of learners and their curricular and assessment information from medical school through residency and practice. With such systems, innovations in medical education could not only measure learner outcomes but also determine how that learning is influencing care (ie, how the learning is being applied and translated). Acknowledging that these will be complex systems with possibly nonlinear relationships between processes and outcomes, we need to complement our armamentarium of research designs with qualitative methods, mixed methods, and social science methods."

O’Malley PG, Pangaro LN. "Research in Medical Education and Patient-Centered Outcomes; Shall Ever the Twain Meet?" JAMA Intern Med. Published online December 07, 2015. doi:10.1001/jamainternmed.2015.6938

Merging the Health System and Education Silos to Better Educate Future Physicians

Ways academic medical centers can integrate the value-based care taught in residency programs into health system leadership, integration and other necessary improvements


Promising Technology
  • By integrating claims, clinical, socio-demographic and care management data that are cleaned, normalized and validated, at-risk patients are identified earlier
  • "Unique capabilities that work seamlessly together to allow providers to expand and evolve all on one platform"
  • Population Analytics platform gives a longitudinal view of one's patient population. "Care patterns, care delivery, clinically driven predictive models, gaps in care, and ACO measure tracking and reporting are all available across disease-specific models"
  • Risk Analytics feature
  • Care Coordination feature–"works to manage care plans and help care teams efficiently develop and track care plans, manage complex patient populations, handle care transitions, identify and close gaps in care, and develop comprehensive patient profiles."

 

Ten Steps That Will Reduce Poor Quality and the Cost of Care

1. Group practice of medicine, preferably operating around a hospital that includes peer review, performance incentives, shared information and a computer-based tracking system.

2. More effective public health and preventive services available to the entire population, based on its dynamic needs.

3. Group-based payment for health services, structured through the use of insurance or taxation for sharing the costs of health care, broadly across people and time.

4. Shared responsibility and accountability by patients, doctors and/or systems of care, as the case may be for: adverse life-style choices where there has been little of no intervention, non-compliance where patients are quite capable of adhering to appropriate medical/surgical recommendations, failure to cost-share and prevent clearly unnecessary care, excesses, and failure to use or follow peer-reviewed standards of care. For more on this very important aspect at the nexus of cost and quality, see "Shared Decision Making to Improve Care and Reduce Costs" by Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. N Engl J Med Jan. 3, 2013; 368:6-8.*

5. Enhance coordination between medical and community services. We also need to make improvements in medical education that will strengthen the social content of curriculum and expand the supply of general practitioners, (in contrast to specialists).  You can even bill for this (even if you are not an accountable care organization). 

The American Medical Association has established codes for transitional care management and complex chronic care coordination; these have been in effect since Jan. 1, 2013. "The hope of those who designed them, said Peter Hollmann, MD, chair of the AMA’s CPT Editorial Panel, is that some practices will use the codes as a means to finance a transition to become a patient-centered medical home, ACO or some other emerging delivery model. Other practices will be able to provide greater care coordination services without necessarily making significant transformations."  

"How physicians can get paid for care coordination." [amednews.com; link not workimg [jgk 12/28/15 PM]

6. Align the incentives to ensure that everyone's on the same page with a single goal of providing efficient, effective, and accessible care. I as a practitioner should be able to earn a premium, the healthier I make you. Should that fail, at least recognize my efforts and its quality. (Note: this is not the same as “pay per performance.”)

The obverse is that there can be no incentives for over-utilizing—for instance, giving unnecessary antibiotics or shotgun, “blind alley” testing. There can be no incentives for under-utilizing, such as, over-referral (i.e., dumping patients), delaying or cutting short5; P.M.] physical therapy, skipping patient education, mental health care, etc.).

Incentives should include, but not be limited to providing payment when pre-established goals and objectives are met. In other words, wherever possible, we should be aligning payment and quality in the interest of motivating improvement.

7. Transparency and public reporting, especially as it pertains to systems improvement such as variance analysis, corrective action planning (CAP), timely feedback and monitoring.

8. Encouraging real, salutary quality improvement It would be misleading to say that mere transparency had motivated surgeons, for instance, to make improvements that they would not have done otherwise. I believe that most if not all concerned professionals are or should be interested in continuous quality improvement. Indeed, I have found that most practitioners will pick up on real or even putative deficiencies, learn from the introspection, and develop new techniques, improving what has to be improved, incrementally if necessary. In "Deaths Drop after Release of Bypass Surgery Results,” [bad link 5/1/16] we note it is not proven that this was cause and effect, but it's certainly suggestive that patients will choose wisely if given the needed information. On the other hand, if you think that certain surgeons, given the spotlight will avoid the riskier cases, we should be seeing a decrease in the number of bypass surgeries. I cannot find any evidence of that. If anything, the average age and number of co-morbidities in bypass cases seems to be increasing.

9. This brings us to the final point of the need to be closing the feedback loop in real-time (ie, at the point of contact with the patient and with believable data). For that one needs acuity adjusted data, which will allow "apples" to be compared to 'apples," rather than when "apples” were being compared to "oranges."

10. Finally, one needs a longitudinal perspective -- all care over time, regardless of setting, the definition of a reliable type of observation -- an 'episode of care.'

* (Item 4, above, continued)

Shared decision making (SDM) can provide numerous benefits for patients, practitioners, and the health care system itself  including informed patient-consumers, greater adherence to orders and care process, better health outcomes, reduced unwarranted variation in both care and costs, and greater patient satisfaction, overall. Indeed, "information gathered by the Patient-Centered Outcomes Research Institute (PCORI) could be incorporated into certified decision aids and used to provide physicians and patients with valuable information for making health care decisions. Data about the effectiveness of shared-decision-making techniques could also be collected and disseminated by PCORI for continuous improvement of these approaches."

Quality Performance Indicators

A NY Times article about tying doctor's pay with the quality of the care rendered proposes 13 performance indicators for what used to be called continuous quality improvement or total quality management under managed care.  Examples: How well do patients feel their doctors are communicating? How many patients with heart failure and/or pneumonia are readmitted to the hospital within a month of admission? How quickly do ER/ED patients go from triage there to a bed on the floor? Are doctors getting to the operating room on time? How quickly are patients being discharged from the hospital?

Union officials propose expanding those 13 indicators to 20 to include giving doctors bonuses for attending community meetings, giving talks, getting special training during work hours, screening patients for obesity, nutritional intake and exercise, counseling to get patients or their families to stop smoking. They have also proposed “excluding some patients — like developmentally disabled patients, homeless people and those who have no place to go — from incentives aimed at reducing the time patients spend in the hospital."

But beware, such indicators can be gamed and doctors can profile and select patients, referring away the sickest.

New York Ties Doctors' Pay to Quality of care." by A. Hartocollis NY Times Jan. 13, 2013

Finally, Cost to Value Ratios

Albeit in the hospital milieu and regardless of any other such late efforts, the United States ranks last when compared to six other countries on the cost to value ratio of care, behind Britain, Canada, Germany, Netherlands, Australia and New Zealand. Indeed, America spends twice as much on healthcare compared to residents of other developed countries, but gets less healthcare quality, efficiency, and equity, according to a “Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally,” a report published June 23, 2010 by the Commonwealth Fund.

The report looks to the healthcare legislation passed acrimoniously in the US designed to substantively improve the cost and quality of our healthcare.


I e-Mailed Karen Davis, PhD, now retired from the Commonwealth Fund and coauthor of the report, to discuss the geo-political disparities pertaining to "value" and benefit realized in various health care systems.  What about America’s performance in healthcare as a nation, particularly in terms of incentives as a means to quality and value improvement is particularly troubling?

Noting that the Commonwealth Fund report "Health Reform's Impact: Health Spending to Shrink by $590 Billion, Family Premiums by $2,000, Over Next Decade,” stated that "significant payment and system reform provisions in the Patient Protection and Affordable Care Act will begin to realign incentives within the health care system and reduce cost growth,” I asked Davis how, exactly, in the ideal, organized healthcare system can or will incentives be realigned? I also asked her whether, knowing what we do from the balloon analogy--if there is evidence that such efforts will have a net positive benefit and whether such efforts could be durable.

Here is what she wrote in response:

Dr. Kaplan,

"Thanks for your nice note and ongoing interest in Commonwealth Fund work. The Cutler-Davis study you mentioned refers to several specific payment and system reform provisions in the Affordable Care Act that change financial incentives within the health system to reward quality and value rather than volume. These include higher reimbursement for preventive care services and patient-centered primary care; bundled payment for hospital, physician, and other services provided for a single episode of care; shared savings or capitation payments for accountable provider groups that assume responsibility for the continuum of a patient’s care; and pay-for-performance incentives for Medicare providers. These provisions, among others, were projected to lead to substantial health system modernization and savings of $590 billion over 10 years."

"Further Commonwealth Fund case studies and reports have shown that successfully realigning financial incentives offers the opportunity to stimulate greater organization as well as higher performance. I’m attaching an article I wrote with Dr. Paulus and Dr. Steele of the Geisinger Health System in Pennsylvania that details some of the successful payment and delivery system changes undertaken there. You may also be interested in the report on realigning incentives and organizing delivery written by several Fund colleagues. We recommend that payers move away from fee-for-service toward bundled payment systems that reward coordinated, high-value care. In addition, we recommend expanding pay-for-performance programs to reward high-quality, patient-centered care."

Clearly, we're on the same page....R.U.?  Please comment; we’d love to hear from you.