Tom Granatir
Sr. Advisor, Clinical Health Policy
ƒ The working theory
ƒ Challenges to BTE implementation
ƒ Implications for policy
1
Crossing the Quality Chasm
IOM Vision – interpreted
EMPLOYERS
CARE SYSTEM
Organizations
that facilitate the
work of patientcentered teams
Supportive
market
environment
High performing
patient-centered
teams
OUTCOMES
•
•
•
•
•
•
Safe
Effective
Efficient
Personalized
Timely
Equitable
GOVT & PLANS
CARE SYSTEM RE-ENGINEERING IMPERATIVES
Redesigned care processes
Effective use of information technologies
Knowledge and skills management
Development of effective teams
Coordination of care across patient conditions, services, and
settings over time
• Use of performance and outcome measurement for continuous
quality improvement and accountability
•
•
•
•
•
1Adapted
from Crossing the Quality Chasm by A. Milstein, 2003.
2
IOM Vision – reinterpreted
EMPLOYERS
CARE SYSTEM
Organizations
that facilitate the
work of patientcentered teams
Supportive
market
environment
High performing
patient-centered
teams
OUTCOMES
•
•
•
•
•
•
Safe
Effective
Efficient
Personalized
Timely
Equitable
GOVT & PLANS
CARE SYSTEM RE-ENGINEERING IMPERATIVES
Redesigned care processes
Effective use of information technologies
Knowledge and skills management
Development of effective teams
Coordination of care across patient conditions, services, and
settings over time
• Use of performance and outcome measurement for continuous
quality improvement and accountability
•
•
•
•
•
1Adapted
from Crossing the Quality Chasm by A. Milstein, 2003.
New Belief System - A dysfunctional market
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No market incentives to improve care and reduce waste
– We pay more for poor quality in rework to compensate for quality defects (readmissions, additional diagnostic or physician care)
– Focus on payment for individual services creates no incentives to organize better
systems of care
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Known quality problems representing 25 – 40% waste
– overuse (needless care that could be harmful)
– under-use (effective care that is not delivered)
– mis-use (poorly delivered care)
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Consumers lack information to guide choices
– Consumers have to seek information about individual providers rather than care
organized around their medical problems
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The only way to find sustainable savings will be by reorganizing care
– Payment strategies that not only reward excellence but encourage the creation of
more organized systems of care
3
The working theory – LFG and BTE
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Leapfrog and Bridges to Excellence grow out of the same
frustration by employers
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They want their contracted health insurers to leverage
relationships with members and networks
– information to members
– incentives for members to choose “best”
– rewards for hospitals and physicians that adopt safe and
effective practices
– network designs that make differences in performance visible
to consumers
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Employers will create incentives for employees to choose
the plans that most actively manage their networks
Bridges to Excellence
ƒ Two very different models
– Certification of process excellence
– Office practice reengineering - creating more “system”
in office practice
ƒ Incentives for patients
– to take more control over their care
– to change their health behavior
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Measuring Physicians & Hospitals
Efficiency
Physicians
Hospitals
Effectiveness
HPN
Self Reported
= NCQA, BTE
Claims Reported = AHM, RAND
Patient Reported = CFP, ACAHPS *
ALOS
Total Cost/Admit
Self Reported
= LFG
Claims Reported = Hospital Value Index
Patient Reported = HCAHPS*
Hospital Value Index
HCUP = Health Care Cost and Utilization Project, tracks in-patient & hospital safety
Challenges
ƒ Employer recruitment
– Tyranny of the “plan year”
– Attitudes toward benefits
– The free rider
– Market makers v. market takers
ƒ Physician recruitment
– Returns to physicians
– Maturity of physician practices
− Ability to respond to incentives
– Mixed incentives
− Administrative burden v. reward
− Disincentives for public recognition
ƒ Patient Incentives
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Challenges
ƒ Provider-specific metrics worthy of consumer choice
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– Quality measures that are scientific & understood by consumer
– Attributable to -- somebody
– Reimbursements bundled in ways that are meaningful to patients
(e.g., episodes of care) and manageable by providers
– Cost measures that clarify the cost consequences of their choices
Plans
– Contracting conflicts
– Market penetration
– Payment system flexibility
– Member retention
– Poisoned relationships and lack of trust
Government – on the sidelines?
Lessons from The Medicare CABG Demonstration
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Global payment to hospital included pre- and post-hospital care
$50.3 million in savings to Medicare over 5 years
Implementation of evidence-based clinical protocols
Innovations in ICU management & nursing deployment (personal
nursing model) led to reductions of 10 - 40 percent in ICU costs
30% reduction in pharmacy cost per case
Significant reductions in inpatient mortality despite increases in case
severity
Improved beneficiary satisfaction
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Implications
ƒ New expectations for the delivery system
– Measurement
– Information systems
– Organized systems of care
– New payment approaches - Global payments for
episodes of care
ƒ Policy implications
– Measurement
– Market-moving demonstrations
– Revitalize global payment demonstrations
– Evaluation support
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