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Sunday, April 9, 2017

Cost, Quality, and Access: The Three Ingredients for a Stable Health Care System






Last week’s post focused on the responsibility of having health care insurance. The purpose of health insurance is to help you pay for care whether it be preventative or diagnostic services. Insurance protects you and your family financially in the event of an unexpected serious illness or injury that could be very expensive. Having health insurance provides access to physicians, providers, and resources to enable your health and wellness.

In this week’s post, I wanted to continue the conversation and talk about two other ingredients essential for a stable health care system; improving quality and containing costs. In 2016, the United States spent $3.2 trillion on health care which comes to about $10,000 for every person. The high cost of health care spending impacts every sector of the economy. As a result, legislative leaders, employers, and the general public are asking the question ‘are we getting a good return on investment for the dollars spent’? To answer this question, I turned to a recent  Commonwealth Fund report that despite having the most expensive healthcare system in the world, the United States ranks last overall among 11 industrialized countries on measures of health system quality, efficiency, access to care, equity, and healthy lives.

The costs of healthcare impacts every sector of our economy. Experts say that we, as a country, cannot sustain the rising costs of health care spending. The Affordable Care Act that was passed in 2010 and put into place incremental efforts to control spending and improve the outcomes across the healthcare system. Today, a great deal of work is being undertaken to find ways to improve quality and slow health care spending. Some of the things that have been implemented include:

Implementation of Health Information Technology: Health information technology is changing the way healthcare is delivered and paid for. It has been said that over the next 8 years, we will see more innovation than we have seen in the last 18 years. Now that the healthcare industry is getting ‘wired’ we are safer, more efficient and able to use data to improve the quality of care provided. We still have a long way to go to make the system interoperable, but efforts are in place to test more and more innovative strategies in place that will revolutionize the industry so that communication is better, the system is more efficient and safer for all who transition through the care continuum.

Payment Models: Up until now, payment models for hospitals, physicians, and other providers were based on paying for products and services. Due to the rising cost of healthcare spending, changes to payment models are being tried in efforts to bend health care spending curve. Examples include; Value-Based Purchasing models that reward physicians and other providers for the quality of care they provide.  Today, due to the information technology systems in place, data is available that allows leaders to see how individual providers are caring for the populations and the outcomes achieved. As a result, new payment models are in place to reward physicians and organization who work with patients and their families in educating them about their conditions and the treatment options in place to treat them. Another payment model being implemented are Bundled Payment Models. Bundled Payment Models are designed to pay multiple providers for coordinating the total amount of services required for a single, pre-defined episode of care. Because we now have a way to collect, analyze and review data on processes and costs, experts have started to put together payment models on procedures that are repeated over and over. For example, planned hip or knee replacements, kidney transplants or care about a myocardial infarction are good examples where bundled payments can be used. By looking at overall costs, hospitals and physicians know what these procedures should cost, how many days a patient should be in the hospital and what therapies, equipment and resources are needed. Taking all the factors into account, payments are now being ‘bundled’. What this comes down to is that physicians and all members of the health care team have to work together to be efficient at every step, from diagnosis to preparing the patient for surgery, to post-op care, in preventing infections and safe discharge planning to avoid a costly setback. Educating and empowerment the consumer is also a critical part of the process, as, without their involvement, none of these models will work. Health care leaders who can operationalize these processes will do well. Those who can not/will not, will not do well under these new payment models.  

Focus on Quality Improvement Efforts: There's never been a more critical time in the history of U.S. health care system for health care professionals to turn to clinical analytics to help them survive — and thrive amidst the trials of health care reform. Overcoming the challenges of reform will ultimately result in improved quality of care delivery and decreased costs. But reaching that point will require significant changes to the way healthcare has historically operated. Health systems need to measure and report on the care they're delivering. They must also understand the financial ramifications of individual care decisions. This approach is quite a change in the traditional fee-for-service business model. But by using clinical analytics to dig into their wealth of captured data, both providers and health systems will be able to gain the critical knowledge they need to answer many questions about care delivery and how to improve it. In addition, federal regulations in the form of incentives are being put in place for providers and organizations who meet certain metrics. Disincentives are also in place for those who don’t meet metrics. National accreditation is another way quality of care can be improved and variation decreased across the broad healthcare system. Accreditation is an evaluative, rigorous, transparent, and comprehensive process in which a health care organization undergoes an examination of its systems, processes, and performance by an impartial accrediting body to ensure that it is conducting business in a manner that meets predetermined criteria and is consistent with national standards. Achieving Accreditation allows all members of the healthcare team from the payer and provider side to have a common bond that is integral to improving the delivery of care and containing costs.  

The Move to Evidenced-Based Care is a causing sea change in how medicine is practiced and delivered in hospitals, clinics and physician practices across the country. Evidence-based medicine includes three key components; research-based evidence, clinical expertise (i.e., the clinician’s accumulated experience, knowledge, and clinical skills), and the patient’s values and preferences. Practicing evidence-based medicine is important in today’s healthcare environment because this model of care offers clinicians a way to achieve the Triple Aim’s objectives of improved quality, improved patient satisfaction, and reduced costs. Payers have systems in place to ensure appropriate use of health care resources through the use of evidenced-based medicine.

Consumer Engagement: A shift is underway as more financial risk in paying for health care migrates from payers to consumers (with providers sharing the risk when individuals cannot pay) and from groups to individuals. For the consumer, this means an increasing obligation to pay a greater share of their health care costs through rising premiums, deductibles, copays, and coinsurance. As a result, consumers are demanding to be part of the decision-making process when it comes to their health and healthcare. In addition, health organizations, physicians, and others are realizing consumers are the most important, yet the most underutilized resource in the health care system. Healthcare organizations are turning to consumers to find ways to provide patient-centered that is safe, high in quality and meets the goals of the individual. If we are honest, the health care system is designed for those who work in the health care system and not the end users, the patient or their families. To re-design the system to be more patient and family centered, patient and family advisory councils are being set up as a way for patients and their families to provide input into their experience, what is important to them when they use the system and what they want to see to improve the system for THE PATIENT and the FAMILY.  Health care professionals also realize that consumers must be educated to take an active role in their health and healthcare. Efforts are being implemented to work together with consumers and their families so that care is based on their goals. Healthcare professionals are being educated in new strategies that they can use to help consumers understand the importance of adherence, behavioral change and active involvement in their health and health care.

Patient Advocacy: the practice of patient advocacy is growing to meet the needs of consumers as they strive to better understand how to use the health care system when they are thrust into the system with an injury or a complex medical or behavioral health condition. Just like a financial planner, certified public accountant or attorney are hired to assist a person with their financial or legal needs, patient advocates are being hired to help the patients and their families navigate the complex healthcare system. Advocates do not provide hands-on care but are in place to do research and advocate on behalf of the person so they have a voice in the system. Advocates come from different specialties and can be found in the hospital or in private practice. Depending on their education and area of expertise, they may specialize in areas such as medical advocacy, medical billing or assisting families when caregiving issues become complex and new living arrangements are needed. Patient Advocates work to take the burden off the patient and their families and guide them through the maze of choices that can meet their needs. Because they are in place for the patient and family, they are objective players and in place to represent the patient and family to the health care team. To learn more about Patient Advocacy, visit the Patient Advocate Certification Board. To find an advocate, visit the AdvoConnection.   

Case Management: case managers are advanced practice professionals who are in place to assist the patient in navigating the complex healthcare system. Case managers can be found at every entry point of the health care system. If a patient or the family member has a question or concern about their care, asking for a case manager can help you find the right person to answer your question, address your concerns and ensure the team is aware of barriers and challenges the patient/family are having. Case Managers are trouble shooters who understand how the system works and can break down barriers and find resources to meet the individual needs of patients and families.  Case managers, regardless of their setting follow a set of standards of practice that guide their practice. 


As you can see the health care industry is undergoing a great deal of disruption as it recalibrates to address the challenges needed to have a stable and efficient health care system in 2017. Redesigning the health care system has been put off due to its complexities of this huge task. We as a country cannot put off this job off any longer due to the rising costs of health care and the impact on our economic health. To be successful, all members of the health care team, payers, and every consumer must be part of the process as we move forward as w cross the quality chasm to build a health care system for the 21st century.  

Thank you for reading Nurse Advocate. I look forward to your comments, insights and recommendations for future comments.