Value in Health Care Accounting for Cost, Quality, Safety, Outcomes, and Innovation: Workshop Summary (2010) / Chapter Skim
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. The Congressional Budget Office estimated that Medicare and Medicaid alone will account for nearly a quarter of the economy by 2050 if healthcare costs grow at just 2 percent more than GDP per capita each year (Congressional Budget Office, 2007)
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Roundtable on Value & Science-Driven Health Care convened a workshop entitled "Value in Health Care: Accounting for Cost, Quality, Safety, Outcomes, and Innovation" in November 2008 at the National Academies in Washington, DC. This workshop was part of the Learning Healthcare System workshop series and aimed to assemble prominent authorities on healthcare value and leaders of the patient, payer, provider, employer, manufacturer, government, health policy, economics, technology assessment, informatics, health services research, and health professions communities.
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Themes touching on the need to improve value and the elements that have to be addressed in achieving this goal included the following: • Urgency: The urgency to achieve greater value from health care is clear and compelling. The persistent growth in healthcare costs at a rate greater than inflation is squeezing out employer healthcare coverage, adding to the uninsured, and doubling out-of-pocket payments -- all without producing commensurate health improve ments.
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Since the starting point for determining value is reliable information, workshop discus sants underscored the importance of appropriate investment in the infrastructure and processes for initial determination and continu ous improvement of insights on the safety, efficacy, effectiveness, and comparative effectiveness of interventions. Action to improve value, then, also requires the fashioning and use of sound decision principles tailored to the circumstances and adequate incentives to promote the desired outcome.
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We have heard that obtaining the value needed will con tinue to be elusive until better means are available to draw broadly on information as to services' efficiency and effectiveness, to set priorities and streamline approaches to filling the evidence gaps, to ensure consistency in the ways evidence is interpreted and applied, and to marshal incentives to improve the delivery of high-value services while discouraging those of limited value. • Communication: System-level value improvement requires more seamless communication among components.
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• Providers: Provider-level value improvement efforts depend on culture and rewards focused on outcomes. Workshop presentations identified several examples of some encouraging results from vari ous programs in terms of progress to improve provider sensitivity to, and focus on, value from health care.
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• Tools: Continually improving value requires better tools to assess both costs and benefits in health care. Despite the broad agree ment on the need to get better value from all the elements of the healthcare process and the commitment to make this a priority, we heard that the analytical tools and capacity to evaluate both of the basic elements of value -- outcomes and costs -- in either absolute or comparative terms are substantially underdeveloped and will need greater attention.
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healthcare costs for the economic crisis, the nation's ability to recover, and the welfare of the American people, before concluding by elaborating on four objectives that should be cornerstones of health reform as we look toward the future: (1) universal coverage for basic and essential health care that meets societal needs, not unlimited individual wants; (2)
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The concept of "measurable clinical efficiency" examines the relationship of composite quality measures as a proxy for benefit and resource use measures, employing standardized prices as the cost function. Quality measures include clinical structure, process and outcome measures of overuse, underuse, and misuse, and patient experiences of care -- each with barriers and problems to implementation and use, he asserted.
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This presentation reviewed the use of medical cost-effectiveness analysis to address these questions. Meltzer suggested that although prevention can be, but is not always, a cost-effective approach to improving health, it is infrequently a powerful approach to controlling healthcare costs, either in the short term or in the long term.
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Descriptions of several key decisions during the life cycle of a healthcare technology illustrated how value is considered in decision making, including the early-phase investment decision by the technology developer, the marketing approval decision by the regulatory agency, the adoption or diffusion decision by the payer, and the individual treatment decision by the patient and the physician. Personalized Diagnostics As a result of the growth of molecular diagnostics, a tremendous wealth of information has been gained about the molecular characteristics of the human genome, according to Ronald E
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Approaches to Improving Value The next set of speakers presented specific examples of current approaches to improve value in health care in three main areas: (1) consumer incentives; (2)
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Fendrick suggested that payers desiring to optimize health gains per dollar spent should avoid "across-the-board" cost sharing and instead implement a "value-based" design that removes barriers or provides incentives to encourage desired behaviors on the part of patients and providers. By aligning financial incentives, he asserted, this strategy would encourage the use of high-value care while discouraging the use of low-value or unproven services and ultimately would produce more health at any level of healthcare expenditure.
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Goetzel of Emory University suggested that the scientific evidence is mounting that worksite health promotion and chronic disease prevention programs can reduce health risks and produce a posi
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Provider and Manufacturer Payments This session explored examples of approaches to improve value in health care, with a focus on the use of payment design and coverage and reimbursement policy to improve value. Pay-for-performance Although the current healthcare financing system encourages the provision of more care, it does little to ensure that individuals receive appropriate care or that the care they receive is effectively or efficiently provided, asserted Carolyn M
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As new knowledge, pharmaceuticals, and technologies become available, he asserted, it is essential that the science, infrastructures, and processes that inform their translation into practice be responsive and robust. The context of unsustainable healthcare costs and related rates of uninsured people, unacceptable deviation of care delivery from evidence-based standards, inappropriate use of expensive healthcare assets, and safety concerns exert significant pressure on all stakeholders to make responsible choices regarding the incorporation of new healthcare assets.
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the exploration of new ways to link coverage and reimbursement to the development and evaluation of better evidence on the value of medical interventions for different types of patients. Organization and Structure of Care This final session on approaches to improving value focused on changing the organization and structure of care to improve value.
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However, for medical homes to profoundly benefit non-affluent adults who do not qualify for Medicaid and persuade most purchasers to pay higher medical home fees, they must also lower total near-term healthcare spending. To achieve such "home run" status, medical homes' design, certification standards, and criteria for reward from payers must explicitly incorporate features from existing primary care practices that achieve low total cost of care and favorable performance on other domains of quality, Milstein stated.
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Next Steps System-Level Efforts Health information technology Since promoting health information technology was the most commonly mentioned priority as a prerequisite for sustained progress toward greater value in health care (improving quality, monitoring outcomes, clinical decision assistance, developing evidence, tracking costs, streamlining paperwork, improving coordination, facilitating patient engagement) , how might Roundtable members and the Electronic Health Record Innovation Collaborative help accelerate its adoption and use?
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Care organization incentives What issues and incentives are needed to expand the development of a medical home model most conducive to more efficient and better-coordinated care? Clustered care for the very sick If, as was presented, there are demonstrated effectiveness and efficiency advantages from certain organizations specializing in the care of the poor and very sick, how can that model of heroism be taken to scale?
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High-cost service evidence Similarly how might an inventory be developed of the top 10 high-cost services for which comparative effectiveness studies need to be done? Capacity for comparative effectiveness research What additional issues need to be engaged to improve prospects for the successful development of a deeper national capacity for comparative effectiveness research?
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2007. The boomers are coming: A total cost of care model of the impact of population aging on health care costs in the United States by major practice category.
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