Evidence-Based Medicine and the Changing Nature of Health Care 2007 IOM Annual Meeting Summary (2008) / Chapter Skim
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7 Policy Changes to Improve the Value We Need from Health Care
7 Policy Changes to Improve the Value We Need from Health Care
Pages 155-172
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From page 155... ...
Experts agree that the way these changes are presented to policy makers and the public will be critical for their acceptance. Moreover, a consensus on how to measure the value of healthcare services is needed to align evidence applications with overall healthcare goals.
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From page 156... ...
Porter defines value in healthcare delivery as patient outcomes achieved relative to the total cost of attaining those outcomes. The implications of measuring value for current approaches to process guidelines, outcomes measurement, and quality and safety improvement are discussed, along with some analytic challenges for the field.
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From page 157... ...
Those who have suggested that universal healthcare coverage is needed before evidence can be incorporated into the system should note that even where we currently have a single payer or a large purchaser, this has still been extremely difficult. It seems logical that very large purchasers of health care such as Medicare, the Veterans Administration, or the military healthcare system should be able to put requirements in place that allow us to take EBM and transform the way care is delivered.
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From page 158... ...
The fundamental problem in achieving universal immunization in this country has always been that a universal healthcare program is not in place. In fact, many thought it would be impossible without this.
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From page 159... ...
In 1991 and 1992, when the Clinton administration was introducing its healthcare reform package, healthcare premiums were increasing and spending on drugs was going up faster (Figure 7-1)
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From page 160... ...
To make a grand social policy change such as providing universal health care, there must be consensus on both the problem and the solution. The mistake we made was that we assumed both existed, but alas, in
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From page 161... ...
Prevailing reimbursement creates a disconnect between profits for system actors and value for patients because providers are rewarded for services, not patient results. System actors are also sometimes rewarded for shifting costs to others. Such a divergence between profits and patient value makes defining, measuring, and reporting value even more essential to true improvements in care delivery.
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From page 162... ...
The costs of achieving outcomes refers to the total costs involved in care, not just the costs borne by any one actor or for any particular treatment or episode. Hence, shifting costs across parties by, for example, raising patient co-payments for prescription drugs, does not add value but simply changes who pays. The mismeasurement of costs works against true value improvement, and is endemic in healthcare delivery in every country, We treat non-economic costs of care, such as the patient's discomfort, anxiety, and time, as part of patient outcomes.
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From page 163... ...
Failure to measure value is the most serious self-inflicted wound of the medical profession and the broader provider community, because it has slowed inno vation and brought about micromanagement of physician practice. Measuring value depends first and foremost on properly measuring health outcomes.
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From page 164... ...
Services are delivered through processes of care delivery that reflect medical knowledge and are affected by patient initial conditions. The care delivery process should strongly influence the outcomes achieved.
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From page 165... ...
To improve value in healthcare delivery, it will also be necessary to measure true outcomes and not rely solely or even predominantly on such indicators. Figure 7-2 also includes patient compliance as an essential factor contributing to health outcomes.
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From page 166... ...
Generic patient satisfaction surveys also fail to capture the specific aspects of health status relevant to each patient's particular medical conditions, which are usually the most important outcomes. While the service experience can be important to good outcomes, it is the outcomes themselves that constitute value.
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From page 167... ...
In fact, one of the principal reasons why value is mismeasured in health care, or not measured at all, stems from faulty organizational structures for healthcare delivery. Patient value is created by the integrated care of a patient's medical condition over the full cycle of care, rather than by a single specialist or by a discrete intervention (Porter and Teisberg, 2006)
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From page 168... ...
Outcomes from a few discrete interventions, or in a few medical conditions, tend to be used as proxies for the overall outcomes of the provider. Current organizational structure in healthcare delivery makes it difficult to measure value correctly.
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From page 169... ...
Outcomes related to safety, such as the incidence of medical errors along with their consequences, are an additional type of outcome measure. To think holistically about outcome measurement for a medical condition, outcomes can be can be conceptualized in a hierarchy, with the most fundamental outcomes, survival and patient health, achieved at the top, and other outcomes arrayed in a natural progression, such as those related to the nature and speed of the recovery process and those related to the sustainability of the results.
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From page 170... ...
A complete understanding of all aspects of such an outcome hierarchy matters more, not less, when different groups of patients value individual outcomes differently. Thus, the first step to a systematic approach to value improvement is a disciplined approach to defining and describing the total set of outcomes.
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From page 171... ...
; endogenizing costs borne by employers or families; aggregating costs for medical conditions over the cycle of care, by aggregating the costs of all the interventions involved; measuring the actual costs, not charges; aligning the unit of reimbursement with the unit of value -- which will require a shift to bundled reimbursement models for medical conditions, in which all physician fees, services, facilities, and drugs over the care cycle are included in a single price; and varying prices according to patient initial conditions. Summary Value must be the fundamental goal of any healthcare system.
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From page 172... ...
Proper measurement of value is the single most powerful lever for improving healthcare delivery. While current organizational structures and practice standards surely create obstacles to value measurement, there are promising efforts to overcome these obstacles.
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