Brian Klepper
What Will It Take To Re-establish Stability and Sustainability to American Health Care? Will It Be Driven Through Policy or the Marketplace?
 
 
 
Problem America’s health care system currently lacks a cohesive management infrastructure for enterprise-wide performance tracking and management. Action Establish the functions described below under the auspices of a new or expanded national agency. Transparency/Accountability Problem Our current inability to identify problems and opportunities throughout health care has resulted in waste, inappropriateness and sub-optimal quality. Broad awareness that excesses are difficult to identify has cultivated an opportunistic culture that permeates the health care sector, and has created a barrier to a functional health care marketplace. Actions Initiate specific efforts that facilitate industry-wide pricing and performance transparency. i. Establish Unique Identifiers For Health Care’s Players and Products Problem The inability to easily identify individual patients, vendors and products hinders management. Action Establish an agency function charged with assigning every patient, health care vendor (e.g., physicians, allied health professionals, hospitals, health plans, manufacturers, suppliers, products) unique identifiers that can be used to facilitate clinical management and performance tracking. ii. Standardize Pricing/Performance Metrics Problem Standardized measurement and reporting metrics are still unavailable for many health care processes, which has hindered interoperability and management. Action Establish an agency function charged with the coordination/oversight of the identification, testing, approval, continual updating, distribution, implementation and efficacy of clinical/administrative measurement and reporting standards within all health care industry sectors and disciplines. Expert not-for-profit (National Quality Forum, HIMSS, NAHIT) and for-profit (e.g., Milliman, Interqual) organizations may develop and update proposed health industry best practice guidelines and measurements/reports, but the agency will have ultimate responsibility for approval of standards. iii. Promote National Implementation of Electronic Health Records Problem Electronic health record systems do not yet adhere to a nationally interoperable standard format, hindering data transfer and aggregation throughout the care continuum. Relying purely on professionals and organizations to invest in these expensive tools, without the incentives of a financial return, is slowing the nation’s transition to a more efficient, effective and accountable health system. Actions A. Establish a national revolving loan fund – A precedent is the 1946 Hill-Burton Act program to build and improve hospital infrastructure throughout America – to facilitate and augment health industry investments in standards-compatible information technologies. B. Establish reimbursement incentives for implementing electronic health records. Phase out reimbursement for providers submitting paper claims. iv. Establish A National Clinical Data Repository Problem Most health care professionals and organizations lack access to complete patient information when making clinical care decisions. Nor is aggregate data available for analysis and management. These issues hinder quality and efficiency. Actions Establish a national clinical data aggregation, evaluation and reporting effort to identify problems and opportunities in patient and population health status, clinical efficacy, and health care vendor performance. Require providers (medical, pharmacy, ancillary) to electronically submit records of all payments by all payers quarterly to the National Center for Health Statistics. Post average Medicare payments for services by region for easy access by consumers. Make data (without patient identifiers) available for purchase to data analysis/reporting organizations. Offer professional reports to providers: i. Professional reports will compare the individual provider performance with that of their peers within specialty (for providers meeting volume thresholds). ii. Professional reports will include care gaps (prevention and chronic disease), efficiency measures (ETG), and prescribing patterns compared to regional and national benchmarks iii. Hospitals reports will include risk adjusted mortality rates, complication rates, and readmission rates compared to regional and national benchmarks iv. Significant outlier reports will include explanations of possible root causes and corrective actions. v. Lists of patients with significant care gaps will be provided. Publicly report individual provider performance compared with regional and national benchmarks (for providers meeting volume thresholds). Personal clinical profiles (past tests, diagnoses, treatments and costs) will be available to patients submitting valid identification. v. Promote National Development Of Evidence-based Best Practice Guidelines Problem Most care and administrative practice does yet not follow evidence-based guidelines. Further, in many cases multiple guidelines have been developed, with a lack of consensus on which guideline should be followed. The resulting variations in care translate to suboptimal quality and inefficiencies. Action Establish national committees of health care experts to establish, continually update and promulgate scientifically-based best practice guidelines for clinical and administrative practice. vi. Transition To Performance-Based Reimbursement Problem Fee-for-service reimbursement promotes excess, rewarding the delivery of more services, independent of their relationship to quality or safety, instead of rewarding the right (safe, effective, patient-centered, timely, efficient and equitable, according to the Institute of Medicine) care. Actions Promote health plans’ transitions to performance-based care reimbursements that reward adherence to best practice, achievement of clinical outcomes targets and efficiencies. Pay top-performing (>50 percentile) providers more. Schedule decreasing payments to poorer performers (≤51 percentile). Make incentive payments for those achieving superior outcomes available only to providers submitting claims electronically. Provide tax credits to payers who report. Establish A National Office Of Health Care Technology Assessment Problem New technologies are often released into the health care marketplace without objective third-party assessments of their value relative to existing products. Action Establish an independent – i.e., isolated from manufacturers – agency dedicated to health care technology assessment and public reporting, prior to release of these products into the marketplace.
Principle 3: Retool Health Care’s Management Infrastructure
Wednesday, October 24, 2007