They might undergo radiology testing this could happen at any point—even before seeing a physician. Each encounter is separate from the others, and no one coordinates the care. Duplication of effort, delays, and inefficiency is almost inevitable. Since no one measures patient outcomes, how long the process takes, or how much the care costs, the value of care never improves.
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The impact on value of IPUs is striking. Patients with low back pain call one central phone number SPINE , and most can be seen the same day.
Those with serious causes of back pain such as a malignancy or an infection are quickly identified and enter a process designed to address the specific diagnosis. Other patients will require surgery and will enter a process for that. For most patients, however, physical therapy is the most effective next intervention, and their treatment often begins the same day. Rather, it eliminated the chaos by creating a new system in which caregivers work together in an integrated way.
The impact on value has been striking. Better care has actually lowered costs, a point we will return to later. Virginia Mason has also increased revenue through increased productivity, rather than depending on more fee-for-service visits to drive revenue from unneeded or duplicative tests and care. The clinic sees about 2, new patients per year compared with 1, under the old system, and it does so in the same space and with the same number of staff members. Wherever IPUs exist, we find similar results—faster treatment, better outcomes, lower costs, and, usually, improving market share in the condition.
But those results can be achieved only through a restructuring of work. Simply co-locating staff in the same building, or putting up a sign announcing a Center of Excellence or an Institute, will have little impact. IPUs emerged initially in the care for particular medical conditions, such as breast cancer and joint replacement. Today, condition-based IPUs are proliferating rapidly across many areas of acute and chronic care, from organ transplantation to shoulder care to mental health conditions such as eating disorders.
Porter, Erika A. Pabo, and Thomas H. By its very nature, primary care is holistic, concerned with all the health circumstances and needs of a patient. The complexity of meeting their heterogeneous needs has made value improvement very difficult in primary care—for example, heterogeneous needs make outcomes measurement next to impossible.
In primary care, IPUs are multidisciplinary teams organized to serve groups of patients with similar primary and preventive care needs—for example, patients with complex chronic conditions such as diabetes, or disabled elderly patients. Different patient groups require different teams, different types of services, and even different locations of care.
Within each patient group, the appropriate clinical team, preventive services, and education can be put in place to improve value, and results become measureable. This approach is already starting to be applied to high-risk, high-cost patients through so-called Patient-Centered Medical Homes. But the opportunity to substantially enhance value in primary care is far broader.
At Geisinger Health System, in Pennsylvania, for example, the care for patients with chronic conditions such as diabetes and heart disease involves not only physicians and other clinicians but also pharmacists, who have major responsibility for following and adjusting medications. The inclusion of pharmacists on teams has resulted in fewer strokes, amputations, emergency department visits, and hospitalizations, and in better performance on other outcomes that matter to patients.
Rapid improvement in any field requires measuring results—a familiar principle in management. Teams improve and excel by tracking progress over time and comparing their performance to that of peers inside and outside their organization.
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Indeed, rigorous measurement of value outcomes and costs is perhaps the single most important step in improving health care. Wherever we see systematic measurement of results in health care—no matter what the country—we see those results improve. Yet the reality is that the great majority of health care providers and insurers fail to track either outcomes or costs by medical condition for individual patients. That surprising truth goes a long way toward explaining why decades of health care reform have not changed the trajectory of value in the system. When outcomes measurement is done, it rarely goes beyond tracking a few areas, such as mortality and safety.
HEDIS the Healthcare Effectiveness Data and Information Set scores consist entirely of process measures as well as easy-to-measure clinical indicators that fall well short of actual outcomes. For diabetes, for example, providers measure the reliability of their LDL cholesterol checks and hemoglobin A1c levels, even though what really matters to patients is whether they are likely to lose their vision, need dialysis, have a heart attack or stroke, or undergo an amputation. Few health care organizations yet measure how their diabetic patients fare on all the outcomes that matter.
The only true measures of quality are the outcomes that matter to patients.
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And when those outcomes are collected and reported publicly, providers face tremendous pressure—and strong incentives—to improve and to adopt best practices, with resulting improvements in outcomes. Take, for example, the Fertility Clinic Success Rate and Certification Act of , which mandated that all clinics performing assisted reproductive technology procedures, notably in vitro fertilization, provide their live birth rates and other metrics to the Centers for Disease Control.
After the CDC began publicly reporting those data, in , improvements in the field were rapidly adopted, and success rates for all clinics, large and small, have steadily improved. Since public reporting of clinic performance began, in , in vitro fertilization success rates have climbed steadily across all clinics as process improvements have spread.
Outcomes should be measured by medical condition such as diabetes , not by specialty podiatry or intervention eye examination. The outcomes that matter to patients for a particular medical condition fall into three tiers. Tier 1 involves the health status achieved. In measuring quality of care, providers tend to focus on only what they directly control or easily measured clinical indicators. However, measuring the full set of outcomes that matter to patients by condition is essential in meeting their needs. And when outcomes are measured comprehensively, results invariably improve. Survival Example: Hip Replacement.
Disutility of care or treatment process for instance, diagnostic errors, ineffective care, treatment-related discomfort, complications, adverse effects. Tier 2 outcomes relate to the nature of the care cycle and recovery. The level of discomfort during care and how long it takes to return to normal activities also matter greatly to patients.
Significant delays before seeing a specialist for a potentially ominous complaint can cause unnecessary anxiety, while delays in commencing treatment prolong the return to normal life. Even when functional outcomes are equivalent, patients whose care process is timely and free of chaos, confusion, and unnecessary setbacks experience much better care than those who encounter delays and problems along the way. Tier 3 outcomes relate to the sustainability of health. It is also one of the most powerful vehicles for lowering health care costs. If Tier 1 functional outcomes improve, costs invariably go down.
If any Tier 2 or 3 outcomes improve, costs invariably go down. By failing to consistently measure the outcomes that matter, we lose perhaps our most powerful lever for cost reduction. Over the past half dozen years, a growing array of providers have begun to embrace true outcome measurement. Many of the leaders have seen their reputations—and market share—improve as a result. A welcomed competition is emerging to be the most comprehensive and transparent provider in measuring outcomes. The Cleveland Clinic is one such pioneer, first publishing its mortality data on cardiac surgery and subsequently mandating outcomes measurement across the entire organization.
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The range of outcomes measured remains limited, but the Clinic is expanding its efforts, and other organizations are following suit. At the individual IPU level, numerous providers are beginning efforts. Providers are improving their understanding of what outcomes to measure and how to collect, analyze, and report outcomes data.
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For example, some of our colleagues at Partners HealthCare in Boston are testing innovative technologies such as tablet computers, web portals, and telephonic interactive systems for collecting outcomes data from patients after cardiac surgery or as they live with chronic conditions such as diabetes. Outcomes are also starting to be incorporated in real time into the process of care, allowing providers to track progress as they interact with patients.
To accelerate comprehensive and standardized outcome measurement on a global basis, we recently cofounded the International Consortium for Health Outcomes Measurement. ICHOM develops minimum outcome sets by medical condition, drawing on international registries and provider best practices. It brings together clinical leaders from around the world to develop standard outcome sets, while also gathering and disseminating best practices in outcomes data collection, verification, and reporting.
Just as railroads converged on standard track widths and the telecommunications industry on standards to allow data exchange, health care providers globally should consistently measure outcomes by condition to enable universal comparison and stimulate rapid improvement. For a field in which high cost is an overarching problem, the absence of accurate cost information in health care is nothing short of astounding. Few clinicians have any knowledge of what each component of care costs, much less how costs relate to the outcomes achieved.
In most health care organizations there is virtually no accurate information on the cost of the full cycle of care for a patient with a particular medical condition. Instead, most hospital cost-accounting systems are department-based, not patient-based, and designed for billing of transactions reimbursed under fee-for-service contracts. In a world where fees just keep going up, that makes sense.
Existing systems are also fine for overall department budgeting, but they provide only crude and misleading estimates of actual costs of service for individual patients and conditions. For example, cost allocations are often based on charges, not actual costs. As health care providers come under increasing pressure to lower costs and report outcomes, the existing systems are wholly inadequate. Existing costing systems are fine for overall department budgeting, but they provide only crude and misleading estimates of actual costs of service for individual patients and conditions.
To determine value, providers must measure costs at the medical condition level, tracking the expenses involved in treating the condition over the full cycle of care.