We are hearing a great deal about changes in the health care landscape that will require a shift in the way we provide care and the way we are reimbursed. We hear about accountable care organizations, acute care episodic plans, bundled pricing and the like, but we have no roadmap to prepare ourselves to move forward given the uncertainty surrounding the nature and structure of health care reform.
What we do know is that change is coming. As a country and as health care providers, we can no longer support ever-escalating health care costs and too-slow (despite our best efforts) progress in improving patient safety, patient satisfaction and clinical outcomes. It is also clear that reimbursement is increasingly being tied to quality and cost outcomes, and patient assessments of their care experiences. The Hospital Consumer Assessment of Healthcare Providers Survey (HCAHPS), developed by the Agency for Healthcare Quality at the request of the Centers for Medicare & Medicaid services (CMS), has already begun collecting and disseminating a great deal of information in this regard.
To be competitive in the evolving health care world, we need to shift from volume-driven to value-driven practice. In order to do this, we need to understand the meaning of value, how to measure and achieve it, and how volume will continue to play a critical role in achieving excellent outcomes but will not be the driving strategic imperative nor the driving reimbursement metric.
Anthony M. DiGioia III
Kevin J. Bozic
Michael Porter and Robert Kaplan of the Harvard Business School have been writing about the need to redefine value in health care for a number of years. They define value in health care, most simply, as outcomes per dollar spent. In order to measure and achieve value as they define it, we need to understand how to accurately measure our outcomes and costs during a full cycle of care (evaluation and diagnosis through treatment, rehabilitation and follow-up care) at the level of medical condition (hip and knee replacement, diabetes, chronic obstructive pulmonary disease, etc.), rather than measuring outcomes of segments of care, episodic treatments and procedures, and measuring costs that are siloed by cost center or department and are estimated at best.
The Porter and Kaplan definition of value is simple, and it is the only definition that integrates the needs of all of the stakeholders — patients, families, providers, payers and government. Measuring outcomes and costs in alignment with this definition of value can be achieved by taking steps to understand and map the actual patient care flow through the full cycle of care, followed by assigning actual cost to each step of the care flow.
Focused care centers
One way of creating value is by developing focused care centers in the form of “hospitals within a hospital.” A focused care center delivers care for a specific medical condition (e.g., hip and knee replacement “homes,” spine care centers, etc.) with dedicated staff and facilities during the full cycle of care. Focused care centers allow us to accomplish the following:
- develop high-performance teams;
- deliver efficient and effective care through both volume and outcomes analysis;
- build a sense of community among patients, families and care givers with a focus on wellness;
- create a user-friendly environment that reduces anxiety while delivering great outcomes;
- provide an environment in which all care givers feel a sense of team, pride and purpose;
- eliminate functional silos with competing priorities (physical and occupational therapists, surgical team, inpatient nurses, etc.);
- manage and focus all required resources (personnel, time and equipment);
- analyze and adjust processes for best outcomes in a timely way;
- assume responsibility for all outcomes and costs; and
- focus on the patient and family care experience.
Focused care centers provide us one structure for achieving volume and value and preparing for the coming changes. How can you get there too?
Patient- and family-centered care
The only common denominator in any system of care delivery is the patient and family, so we must place our focus there; if we are to achieve true value for patients, then we must find new ways to understand their expectations and needs during the full cycle of care and include them as partners in redesigning care delivery. Building on an understanding of our outcomes and costs for each medical condition, we can begin to identify and implement actions and activities that will create and improve value. We propose that these actions and activities must focus on value as defined by patients and families. There are a number of tools, in addition to HCAHPS surveys as previously noted, that can be used to understand and then optimize the care experiences of patients and families:
- Shared decision making provides for an exchange of information between patients and their physicians to identify patient preferences regarding health states and willingness to pay (http://informedmedicaldecisions.org/).
- Shadowing and care experience flow mapping is the repeated real-time observation and recording of patients and families as they move through the defined care experience, a key step in the Patient and Family Centered Care Methodology and Practice (PFCC M/P).
- Registries are a repository for collecting and reporting uniform outcomes data for specific patient populations categorized by disease or medical condition. They can be used to benchmark and compare clinical and cost-effectiveness of patient care activities (www.effectivehealth care.ahrq.gov/repFiles/patoutcomes.pdf).
- The Patient Reported Outcomes Measurement Information System (PROMIS), funded by the National Institutes of Health, is a system of highly reliable measures of patient-reported health status for physical, mental and social well-being. PROMIS tools measure what patients are able to do and how they feel by asking questions. These measures can be used as primary or secondary endpoints in clinical studies of the effectiveness of treatment (www.nihpromis.org/about/abouthome).
- Time-Driven Activity-Based Costing (TDABC) and Outcomes Measurement combine an easy and powerful approach to measuring cost along two parameters — how much does it cost to supply the resource capacity for each care delivery activity and how much time is required for each activity — with an outcomes hierarchy tool that measures specific metrics and risk factors including those that are most important to patients and families.
- The PFCC M/P is a simple mechanism for developing focused care centers. It brings all of these ideas together in one methodology for viewing care through the eyes of patients and families with the singular goal of delivering exceptional care experiences through the full cycle of care, which begins with the first phone call and arrival at the parking garage through to diagnosis, treatment, rehabilitation and follow-up care. A simple six-step process, the PFCC M/P involves front-line care givers, patients and families, in a way that creates both urgency and ongoing partnership in co-designing care delivery to drive change (www.pfcc.org). The PFCC M/P has been used in a robust real-world academic medical center environment, in more than 40 different care experiences and medical conditions as diverse as hip and knee replacement, bariatrics, breast cancer care, level 1 trauma care and home health care, with excellent outcomes in patient satisfaction, clinical metrics, waste and cost.
As physicians, we are pulled in many competing directions each day. Our jam-packed schedules leave little time to focus on understanding what is important to patients. We do not always understand the outcomes that are important from our patients’ perspectives or our true costs at the level of the medical condition, and it is difficult to imagine how to quickly and effectively make these paradigm shifts so that we are prepared for whatever care and payment structures result from current and future health care reform activities.
With the patient at the center, we can gather all of the information we need to understand and transform clinical outcomes, patient-reported outcomes, patient and family experiences, and costs. We can put patients at the center by viewing care as an experience through the eyes of patients and families; co-designing care with patients, families and caregivers; and implementing a methodology to go from the current state to the ideal care experience. Focused care centers can provide us with the structure within which to put the patient at the center of care redesign.
Focusing on the care experience, rather than the service line, on providing exceptional experiences, rather than volume, will help us to achieve the needed transformation in care delivery. Physicians must lead the way in building exceptional care teams and making the shift from volume to value. Refocusing on the needs and desires of our patients and families to improve outcomes per dollar spent is the way to create value-driven practices.
- DiGioia AM, Greenhouse PK. Care experience based methodologies: Performance improvement roadmap to value-driven health care. Clin Orthop Relat Res. 2012;470(4):1038-1045.
- DiGioia AM, Greenhouse PK. Design Science can help achieve the triple aim set of goals. Ortho Today. 2011;31(10):27-28.
- Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477-2481.
For more information:
- Kevin J. Bozic, MD, MBA, can be reached at University of California, San Francisco, 500 Parnassus, MU-320 W, San Francisco, CA 94143; 415-476-3320; email: email@example.com.
- Anthony M. DiGioia III, MD, is the editor of Emerging Technology & Innovation. He can be reached at firstname.lastname@example.org.
- Disclosures: Bozic is a consultant for Pacific Business Group on Health, Integrated Healthcare Association and the Blue Cross Blue Shield Association. DiGioia has no relevant financial disclosures.