Want health reform? Change these 6 things all at once

The most interesting thing I read recently about health care was a Harvard Business Review article by economist Michael Porter and Thomas Lee, the chief medical officer at South Bend-based health information firm Press Ganey Inc.

The article, titled “The Strategy That Will Fix Health Care”, calls for the U.S. and foreign health care systems to embrace a “value agenda.” That is to say, an agenda that seeks to achieve the best outcomes for patients at the lowest cost.

Of course. Who’s against good outcomes at low cost?

The entire U.S. health care system, that’s who.

“While health care organizations have never been against improving outcomes, their central focus has been on growing [patient] volumes and maintaining [profit] margins,” Porter and Lee write. “Despite noble mission statements, the real work of improving value is left undone.”

There have been many efforts to change this focus on volumes and profits, but Porter and Lee run down how all of them have failed because they usually try to change only one of about seven interlocking pieces of the health care system.

Those seven pieces are: 1) independent physicians organized by specialty, not patient needs; 2) quality measurements based on process compliance, not patient outcomes; 3) accounting for costs based on fictitious charges, not actual costs; 4) fee-for-service payments with myriad cross-subsidies between lucrative procedures/patients and money-losing ones; 5) a fragmented industry of health care systems and rampant duplication of services and facilities; 6) fragmented patient populations that prevent providers from specializing in certain diseases; computer systems siloed by medical specialty or function.

The net result is that the United States spends twice as much per person on health care than the next most spendthrift nation, and sports poorer overall health to boot.

So Porter and Lee call for simultaneous action on no less than six fronts.

1. Organize health care providers into integrated units focused on specific patient needs: For example, Porter and Lee suggest teams of clinicians that focus on diabetes, as well as the kidney and eye disorders that advanced diabetics develop. Another example is a team of cancer specialists that team up with palliative care providers to treat patients with metastatic cancer. These teams would also provide education and counseling to patients and their families to encourage adherence to treatment regimens and promote needed changes in behavior, diet and exercise habits. These teams would have a single system for scheduling and administration.

2. Measure outcomes and costs for every patient: These integrated health care teams must move beyond the rudimentary quality metrics now used, which primarily measure quality based on whether certain processes were correctly followed. Instead, these integrated would use or in many cases develop metrics for actual patient health as well as actual costs to patients (and their health plans).

3. Move to bundled payments for care cycles: Hospitals and doctors are now, in most cases, paid a separate fee for each thing they do to a patient. Porter and Lee want to implement a system that would pay each team of clinicians one fee to care for each patient. For an acute care patient, such as a patient who comes to a hospital for surgery, the bundled payment would cover all care needed to prepare, cut and convalesce the patient. For patients with chronic diseases, a bundled payment would cover all necessary care for a year (or some other length of time). For primary care, there would be bundled payments for different types of patients: healthy children, healthy seniors, etc.

4. Integrate health systems: Porter and Lee don’t mean just bring more hospitals and doctors under a common name, as nearly all Indianapolis-area hospital systems have been doing. Rather, they want all health systems to do these four things: 1) reduce or eliminate services in which a health system can’t produce high value for patients; 2) concentrate remaining services in fewer locations; 3) steer patients to the lowest-cost location for a service (home care first, then outpatient clinic and, only when needed, a hospital facility); and 4) create administrative systems to allow patients to move from one location to another without glitches.

5. Expand geographic reach: Simply put, health care providers that achieve region- or nation-leading value in certain medical conditions need to expand regionally or nationally to provide that service to more patients. Today, even most academic medical institutions, such as Indiana University Health, derive the overwhelming number of their patients from their immediate local area.

6. Build an enabling information technology platform: IT up until very recently has been about automating existing work functions. But, as Porter and Lee point out, “automating broken service-delivery processes only gets you more-efficient broken processes.” They call for new kinds of IT systems that are organized around patients and all data related to them, that make that information easily available to all members of the integrated team, use common data definitions across all medical specialties, and which allow easy extraction of information for generating reports on outcomes and costs.

That’s a tall order. Perhaps an impossible one, although Porter and Lee cite existing health systems that are implementing some of their six-part strategies already—and achieving good results.

Porter and Lee believe that the health systems that embrace the value agenda most aggressively will be the winners financially–even before the rules from government agencies and private health insurers fully change to pay them for value.

“As should by now be clear, organizations that progress rapidly in adopting the value agenda will reap huge benefits, even if regulatory change is slow,” they write. “As [integrated health care providers’] outcomes improve, so will their reputations and, therefore, their patient volumes. With the tools to manage and reduce costs, providers will be able to maintain economic viability even as reimbursements plateau and eventually decline.”

Check back in about five or 10 years to see if they’re right.