Expanding health insurance coverage not enough
While expanding health insurance coverage is a necessary and important step in health care reform, it will fail if it is not coupled with actions to address quality and cost, according to officials with a number of quality and other stakeholder organizations. The authors, representing groups such as the National Committee for Quality Assurance, the Quality Forum, the Center for Medical Technology, and the New America Foundation, lay out their building blocks for a high-performance health system in a Health Affairs article intended to influence whoever become the next president of the United States.
"Quality improvement, cost containment, and coverage expansion are intricately interwoven goals," they say. "To achieve and sustain broad-based access to high-quality, affordable care requires understanding and eliminating major structural barriers that impede the development of a high-performance U.S. health care system."
National Quality Forum CEO Janet Corrigan, one of the lead authors, tells State Health Watch those who wrote the paper "want everyone to receive the services that will benefit them. So we need to expand coverage, but we also need to improve the health care delivery system. Today, whether we have insurance or not, we have only a 50-50 chance of receiving all of the health care services that would benefit us. We believe that for any reform package to be successful, it must not only pay attention to extending insurance coverage, but also to creating a delivery system that can provide the care that people need and would benefit from."
Policy changes outlined in the paper have three objectives: 1) to develop the science base needed for better decision making in health care; 2) to structure a combination of performance reporting and payment policies that would facilitate development of more effective and efficient models of care; and 3) to marshal broad-based efforts in the health care delivery system and elsewhere to avert dire health and financial consequences from population health problems such as obesity.
"These objectives are inherently linked," the authors contend. "A solid base of evidence enables rational decision making about health care and development of robust measures of quality. Credible performance evaluation is essential to recognize and reward high levels of performance for patients and populations. Strong incentives are needed to encourage diverse health care providers and other stakeholders to take on the hard work of cultural and organizational change that is needed if we are to achieve consistently high performance in health care."
Reliable information is the base
According to Ms. Corrigan, a fundamental building block of any high-performance health system is reliable information about the effectiveness of care, including benefits, risks, and costs of alternative technologies and services. The authors say evidence is needed to support national and regional decisions about Medicare coverage, development of practice guidelines and performance measures, design of value-based insurance plans, and informed patient and clinician decision making about treatment alternatives.
To that end, the authors see a need for a "major initiative to systematically identify where critical gaps in evidence exist, prioritize those questions, and efficiently generate evidence that is relevant and adequate to fill the gaps."
A fundamental barrier to a high-performance health care system seen by the authors is the severely fragmented configuration of the current delivery system, which they see as being ratified and reinforced by payment policies and performance measures. They say the inadequacy of current organizational models are most evident for the sickest patients, who typically see multiple physicians and often move across multiple settings. Such patients, they say, are at risk for miscommunication, redundant testing, and dangerously uncoordinated care.
While the health care leaders support expansion of health information technology (IT), saying it offers tremendous opportunities to make care safer and more effective and efficient, they say IT alone will not solve the problem. They also call for efforts to enable and support clinical entities that can coordinate care across providers and settings, deliver against coherent care plans, and be accountable and rewarded for performance.
The paper's authors say transitional strategies will be needed to evolve from a highly fragmented delivery system to one made up of high-performance organizations. "The challenge," they say, "is to develop performance measurement systems and payment policies that will encourage physicians, medical groups, hospitals, and other providers to develop models of care that can evolve to produce excellent results across the entire delivery system. No single organizational model would work in all circumstances, but we should promote the development of a variety of 'accountable health care entities.' Primary care physicians could create 'medical homes.' Multispecialty groups and independent practice associations with and without hospitals might form the nexus of virtual groups. They could be held accountable for outcomes for their patient populations across providers and over time and for delivering health management through clinical systems such as registries, electronic prescribing, electronic health records, coordination of care, patient education, coaching, and self-management functions (either internally or through partnerships). The way to encourage development of such entities is to pay them to take on those responsibilities and reward them based on performance."
'Misaligned incentives' a root cause
Ms. Corrigan says the primary causes of the poor quality and excess costs that characterize the current health care system are misaligned incentives inherent in payment approaches. But focusing on cost and quality separately is the wrong way to solve either problem, she says. "We believe that if quality is not tied to payment, providers' behavior will not change appreciably, and if it does not change, access to insurance and care will continue to decline," she and the other leaders wrote.
The authors say the still-dominant fee-for-service payment system needs to be replaced with payment models that reward clinically effective and efficient population health management and that yield high levels of patient satisfaction. A variety of models should be pursued. Where integrated systems exist that can take responsibility for comprehensive and proactive health management of patient populations, the goal should be to pay them for population health outcomes through severity-adjusted bundled payment (full capitation). Where integrated systems don't exist, other payment methods should be tried that reward coherent and proactive care and encourage efficiency, such as bundled chronic care episode payments.
They say the transition to paying for quality will require the concerted efforts of public- and private-sector payers to create a business case for providers to change how they operate.
Steps that Congress and others can take now to move toward meaningful change include:
1. creating a national center to support effectiveness research, with stable public-private funding;
2. encouraging the Centers for Medicare & Medicaid Services, state Medicaid programs, and private purchasers to continue developing and testing models of accountable health care entities that achieve effective integration and coordination of care for the populations they serve;
3. encouraging public and private purchasers to develop payment methods to reward high-value care, such as shared savings models and bundled severity-adjusted payments, while ensuring a high degree of transparency of information on quality, cost, and use patterns;
4. developing a national strategy for performance measurement, including standardized measures of patient and population health;
5. pursuing a comprehensive approach in the public and private sectors to improving population health with measurable goals and resources tied to achievement of goals.
Debate hard to sustain
"Opportunities for true national debate over the direction of U.S. health care are rare and difficult to sustain," the paper says. "If the current surge in interest in system reform is to succeed in the near and long terms, it must concurrently address coverage, costs, and quality. By expanding the knowledge base to support rational decision making, by transforming outdated payment systems and building a national performance measurement strategy, and by integrating quality considerations into decisions about everything from benefit structures to public health strategies, we can create reform that reaches well beyond better coverage to better health care and better health."
Ms. Corrigan tells State Health Watch that one reason our health care system isn't functioning well is that it was designed decades ago to deliver acute care services. But today the majority of people have chronic conditions that need to be managed over time. Without good coordination of care, patients often go to multiple doctors at multiple treatment sites for multiple chronic conditions.
A significant problem, she says, is that the system is highly decentralized, with multiple providers in multiple settings and services that are not coordinated. In addition, little information travels with patients as they go to the various providers. "There's no electronic health record that travels with patients and there's not very good communication between providers for coordinated treatment plans," Ms. Corrigan says.
Because medical knowledge is expanding at an extraordinary rate, she says, there now is more information than any one doctor could possibly keep in his or her head. As a result, she says, we need clinical decision tools to help doctors do the right things for their patients. And we need to standardize care processes wherever possible.
Looking at the possibility of changing payment mechanisms is important, Ms. Corrigan says, because current payment policies reward volume and fee schedules don't cover many valuable services such as care coordination and patient education.
Pursue all recommendations
Asked if there is a priority among the groups' recommendations, Ms. Corrigan says she believes they should be pursued in tandem, although there are incremental steps that can be taken with each one. Prior efforts at broad health care reform have not been successful, she says, because it is so complicated. "Change involves many people and many companies," she says, "and we need to have a coherent plan. We need to recognize that if we can't make strides in each area, we can't accomplish overall reform."
Federal leadership is important to health care reform, according to Ms. Corrigan, because Medicare and Medicaid are the first- and second-largest payers for health care services. "If we have federal leadership, we can begin to make changes in federal payment mechanisms," she says. "We also need the federal government to coordinate with private-sector leadership."
Ms. Corrigan says she and her colleagues recognize the political context that surrounds their recommendations. She describes the paper as a call to action for whoever wins the election this fall and will be our next president. But Ms. Corrigan says it's also a call to action for state-level leadership. "I'm optimistic that we can make strides," she declares.
Access the article at http://content.healthaffairs.org/cgi/content/full/27/3/749?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=o%27kane&andorexactfulltext=and&searchid=1&FIRSTINDEX=0& resourcetype=HWCIT. Contact Ms. Corrigan at (202) 783-1300.
While expanding health insurance coverage is a necessary and important step in health care reform, it will fail if it is not coupled with actions to address quality and cost, according to officials with a number of quality and other stakeholder organizations.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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