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CCH® BENEFITS — 02/04/09

Health Care Delivery Reform Requires Improved Coordination, Payment Systems, Focused Policy Agenda

from Spencer’s Benefits Reports: Reforming health care delivery into a system delivering high value requires stronger organizational capabilities and support; payment and capital investment systems aligned with value; and a focused policy agenda, according to an article published online in the January 27 Health Affairs. In the article, Building Organizational Capacity: A Cornerstone of Health System Reform, leaders from the National Quality Forum asserted that U.S. health care currently is not a “system,” because care too often is uncoordinated and fragmented, and suffers from lack of a common strategy and accountability for continuity of care. Furthermore, the current health care structure “seldom achieves the promise of consistently high performance seen in other sectors of the economy.”

The current health care model is afflicted with “entrenched overuse, misuse, and underuse of services particularly for care coordination, patient education, electronic visits, primary care, and discharge planning.” Gaps in quality, use, and access to care are particularly burdensome to minority populations, the article points out. In addition, the prevailing fee-for-service payment scheme encourages volume of services, particularly for well-paid services, rather than focusing on patient outcomes. The result is an estimated 30% to 40% of health care services represent waste. Savings from reducing overuse must be reallocated to underused services, the authors asserted.

“Systems of care must change with the development of new organizational models capable of consistently providing effective, safe, and efficient care across each entire patient-focused episode,” the article noted. However, a stumbling block to implementing value-based systems of care is the dearth of information on the effect of health care on patient outcomes.

The Institute of Medicine has called for new organizational models that are able to do the following:

• invest in health information technology (IT);
• manage clinical knowledge and skills;
• design processes of care based on best practices;
• assemble and use multidisciplinary teams;
• coordinate care; and
• measure and improve performance.

“Principles of professionalism must evolve to address the responsibilities of clinicians to shape organizational missions, governance, cultures, policies, and care processes that are in the best interest of patients,” the authors insisted. “To achieve this kind of cultural transformation, strong leadership will be needed to institute changes within medical education, residency training, and board certification programs and to assume leadership positions within emerging organizational arrangements.”

With respect to quality and efficiency of care, multispecialty group practices outperform smaller, less organized practices, although these less organized practices can align themselves with large organizations to gain the advantages of a multispecialty practice. Multispecialty group practices generally have access to funding and expertise, as well as to the resources for clinical care integration (providing most of the care necessary for the chronically ill for the duration of their illness) that leads to higher levels of performance. Health IT can result in “significantly” improved quality, efficiency, and costs; provide computer-assisted decision support; and enable utilization of medical advances.

Payment reforms must include expanding the list of reimbursable medical services (such as care management and discharge planning), replacing fee-for-service with bundled payment for patient “episodes” (for example, for a 12-month period to manage the patient’s chronic medical conditions); and expanding capitation. Bundled payment might use evidence-based costs of all care for a medical condition. All payment systems must include performance measurement and public reporting of performance.

Finally, the authors called for a national policy agenda to encourage organizations to achieve high-value health care incorporating the following six functions:

1. setting national priorities and goals;

2. making major improvements to a national standardized measurement and reporting infrastructure to assess value;

3. making fundamental payment reform;

4. establishing community-level initiatives to implement public reporting and payment reform;

5. providing federal leadership in health IT standards development and financial incentives; and

6. fostering public education to participate in reform of the health care delivery system.

“There is a great deal of consensus on what needs to happen, but the status quo has always commanded an enduring position in health care reform,” the authors concluded. “Leadership, multistakeholder engagement, strategic intentionality, and consistent execution of policy solutions are needed.”

For more information, visit http://www.healthaffairs.org.

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