Cutting health care costs through better care delivery

Discussion in 'Healthcare/Insurance/Govt Healthcare' started by Greenbeard, Jun 4, 2011.

  1. Greenbeard
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    Greenbeard Gold Member

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    There was a very interesting paper in Health Affairs a few days ago, "How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts," in which two delivery system experts at Intermountain Healthcare explain how Intermountain has been improving care and working to contain costs for the past 25 years.

    In numerous threads I've emphasized the need for health reform of any kind to be conceptualized as a quest for better value (health outcomes achieved per dollar spent) in our system; reform that doesn't seek to improve value will invariably be woefully inadequate. Intermountain offers an example--though only one example--of what pursuing value looks like.

    Intermountain is an integrated delivery system in Utah and Idaho consisting of 23 hospitals and 160 clinics. They consistently rank among the best integrated health care systems in the country (they've been number one in the Modern Healthcare ranking five times in the past decade or so), based on factors like efficiency and quality of care. The paper, as the title suggests, outlines how they've climbed to the top, trimming costs by improving care quality (i.e. increasing value). Some of the key points:

    • Processes of care. Honing in on certain common treatments at Intermountain by breaking each treatment down into the elements it was composed of revealed that no doctors were consistently very good or very bad across all the elements of the treatment: "the findings forced Intermountain to focus on the processes of care delivery that underlie particular treatments, rather than on the clinicians who executed those processes."
    • Evidence-base care.The development of evidence-based clinical practice guidelines for providing various treatments (built into clinical workflows so doctors didn't have to remember to implement them, e.g. these elements were present during care delivery in things like checklists), paid big dividends:
      "In the subcategory of patients who were most seriously ill with acute respiratory distress syndrome, applying this method reduced the rate of guideline variances from 59 percent to 6 percent within four months. Patient survival increased from 9.5 percent to 44 percent; physicians’ time commitments fell by about half; and the total cost of care decreased by 25 percent."​
    • Data, data, data. (i.e. quality measurement and informed clinical decision-making)
      • Generate/acquire data. Intermountain pursued a "measurement for improvement" strategy by implementing new clinical management information systems. This strategy "focuses on the processes of care delivery rather than the providers who execute them, and it generates data for front-line process management and improvement."
      • Use data to improve care. Using data to identify and measure quality isn't enough. Intermountain reorganized the delivery of care to improve clinical care, in part by using physician-leader/nurse administrator pairs ("clinical leadership dyads") to help clinicians improve their practices using the available data. "They use the clinical management information system to review data on clinical, cost, and service outcomes for each care delivery group. More important, the clinical leadership dyads from across the entire Intermountain system meet monthly as a group to identify and address improvement opportunities. They test possible solutions and disseminate successful results. "

    It's worth noting that the authors emphasized the need for payment reform, lamenting the current volume-based incentives that have hurt Intermountain as it saved money and improved care by reducing unnecessary service volume:

    And, of course, the paper ends with reflections on the current period of health reform:

    This, what Intermountain has done and what the ACA is attempting to incentivize and stimulate, is what health care reform looks like: building a high-value health system by improving the way we pay for and deliver care.
     
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  2. Oddball
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    Oddball BANNED Supporting Member

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    Boring bullshit text wall unread.

    The problem with medical costs it too much third-party interference between the customer and the provider, not "reformed" methods of it.
     
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  3. Mad Scientist
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    Mad Scientist Deplorable Gold Supporting Member Supporting Member

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    The only thing Gov't can do right is bomb foreign countries. Gov't should leave everything else alone.
     
  4. Oddball
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    Oddball BANNED Supporting Member

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    Here comes Obamacare's Big Brother: Accountable Care Organizations - CSMonitor.com
     
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  5. Greenbeard
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    Greenbeard Gold Member

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    Intermountain, of course, is just one example of using delivery system innovations to improve the value of health services. Other integrated health systems around the country that are known for providing high quality care at lower-than-average costs offer even more perspective on what works.

    The Cleveland Clinic has organized into a continuum of care delivery model: it has a tiered system in which a regional network of providers works in concert to provide a level of care appropriate to the patient's needs. But how is care coordinated and how are transitions between clinics/hospitals/etc made seamless?

    Or look at some of the payment innovations that have come out of Geisinger in Pennsylvania:

    A bit more on the Geisinger model which, similar to Intermountain and the Cleveland clinic, is based on access to and use of data/information (e.g. using electronic medical records or using quality measurement to gauge performance), adherence to evidence-based processes (see the "ProvenCare" protocols), patient-centeredness, and payment that transfers some risk (and accountability) to the provider:

    The Mayo Clinic actually has its own Center for Innovation aimed at exploring new delivery models and "using a patient-centered focus to transform the experience and delivery of health care for patients everywhere." One of the initiatives they helped to launch recently was a variant of the patient-centered medical home model in one of Mayo's medical centers:

    To anyone familiar with the health care reforms being implemented now, these concepts won't be new; however, they do offer clues as to what a high-performing, high-value health system would look like and thus what reform should encourage if we want to contain costs without compromising quality.
     
  6. Mad Scientist
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    Mad Scientist Deplorable Gold Supporting Member Supporting Member

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    All these things you talk about are just fine when it relates to the private health sector. But the problem is that you and others like you want the gov't to take it over and turn it into a money wasting, bloated, bureaucratic monstrosity.

    Why do you want to destroy health care in this country? :confused:
     
  7. Greenbeard
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    Greenbeard Gold Member

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    Take over what? What you'll notice is that these high-value examples are not simply Hospital X in Podunk, USA, they're specific structures (integrated health systems). Virtually all of them have an insurance plan associated with them, though they generally take patients from external commercial payers, as well. That insulates them a bit from the forces driving the rest of the nation's providers, though it doesn't completely protect them.

    The reason the rest of the country--providers who aren't in the Mayo system, or the Cleveland Clinic network, or Geisinger--often can't do what they do is that the incentives are misaligned, structural barriers stand in the way. What did the Intermountain guys say about some of the broader reforms in the ACA? "They reflect sophisticated forms of provider cost sharing...". You're not going to get that (outside of the integrated delivery systems) without policy changes and even the integrated systems could benefit from payment reforms so that they're actually rewarded instead of penalized for lowering costs, as the Intermountain folks noted.

    None of that just happens. If I were to get treatment in the Cleveland Clinic network and then for some reason later seek treatment at a Geisinger facility, the fact that both have sophisticated EMR systems may not lead to coordinated care and information at the point-of-care when the physician needs it. That's because electronic medical records generally don't cross organizational boundaries; they're excellent if you're staying within the Cleveland Clinic's system or within Geisinger's system but if we want broader interoperability (signified by a slight terminology shift: electronic health records) we need more. Ohio and Pennsylvania will both need to have infrastructure for health information exchange between any providers in their respective states and those two state infrastructures will need to be able to talk to each other using national standards. All of that is being built now but it doesn't just happen by accident, any more than the interstate highway system built itself by accident.

    Your ideology is blinding you into thinking there's a "government takover" of something (it's unclear what) when in fact we need policy changes to spread the innovations that are working in the industry leaders (even the industry leaders themselves recognize this and are asking for those policy changes). In other words, the private sector is still going to be doing these things under reform, not the government. The point of reform is to remove the structural barriers that prevent them from doing this.
     
    Last edited: Jun 5, 2011
  8. boedicca
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    boedicca Uppity Water Nymph Supporting Member

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    What's really amusing is that Intermountain Healthcare is focused on these efficiencies all on their own without being ordered to and micromanaged by the HHS. Any properly run health care organization is always seeking productivity improvements (which makes the cost saving assumptions in ObamaCare even more bogus).
     
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  9. Quantum Windbag
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    Quantum Windbag Gold Member

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    There is actually a major difference between the two.

    Intermountain conducted a long term study with the intent of increasing profits. The government intends to control cost by central committee and fiat. One works because it increases productivity and reduces costs, the other fails because central planning cannot adjust to conditions on the ground.

    Not that I expect you to understand this, if memory serves you tend to run and hide when something you masters have you post turns out to prove the opposite of what they think it does. That indicates to me that whoever you work for it is not the government because they they know enough to minimize their losses.
     
  10. rdean
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    rdean rddean

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    Health Care companies operated with a "profit motive".
     

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