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:
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.
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:
As Intermountain teams implemented clinical management, clinical outcomes improved and costs fell. However, our payments also felloften even further than our operating costs. For example, although improvement in Intermountains appropriate elective induction rates saved the citizens of Utah more than $50 million per year through reduced payments, Intermountains costs fell by only about $41 million. Intermountain thus lost more than $9 million per year in operating margins. Implementing better care required us to invest in education, work-flow redesign, and new data systems. As we improved, the resources to drive further change disappeared.
And, of course, the paper ends with reflections on the current period of health reform:
From 1993 through 2000, total health care delivery costs for the United States remained at a relatively stable 13.7 percent of gross domestic product. This is the only period when the United States bent the cost curve for health care.
Although part of the reason for this success was the rapid growth of the US economy, the main contributor was the health maintenance organization movement, which included a payment system that put care providers at financial risk for their decisions to use health care resources. The movement eventually failed because of perceptions that it gave health care providers incentives to withhold necessary care, thus damaging quality. Even though empirical evaluations showed no worse, and sometimes slightly better, clinical outcomes, health maintenance organizations were not able to overcome these perceptions. Questions about limiting patients choice of providers also contributed to the movements demise.
The Affordable Care Act of 2010 aims to extend health insurance coverage substantially, and the Congressional Budget Office has estimated the number of people who will become newly insured at thirty-two million US citizens. Achieving that goal requires that growth in health care costs be brought under control.
All of the acts major initiatives to reform the care systemsuch as accountable care organizations and patient-centered medical homesare intended to bend the cost curve. They reflect sophisticated forms of provider cost sharing, an approach that differs from the health maintenance organization in three major ways.
First, in the past twenty years we have seen great improvement in the science of clinical risk adjustment and quality measurement. Well-organized care delivery groups can apply that science to generate and use robust measures that lead to effective care management. Second, the groups charged with managing the care are clinical teams at the bedside, not distant health insurance companies. The third difference between the new organizational structures proposed in the Affordable Care Act and health maintenance organizations is a major advantage for the former: When a care delivery group reduces health care costs by improving clinical outcomes, some of those savings will flow back to the clinical teams that delivered better care. This aligns financial incentives with efforts to improve clinical quality.
Taken together, these policy changes are crucial. Truly managed care means organized carecare whose hallmarks include rich clinical and financial data that inform the decisions of clinical teams at the bedside; and clinical teams that employ patient-centered care processes leading to improved population health. Researchers must partner with practitioners to evaluate and demonstrate innovative financial alignment models. A central challenge for policy makers now is to align financial incentives and drive the transition to organized care systems that can provide the best clinical result at the lowest necessary cost.
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.