Outcomes and costs are not independent Cost containment model doesn’t work; we’ve tried it for 20-30 years, need a new model The system isn’t organized to create value E.g., through the right diagnosis (Cleveland Clinic second opinions example – 17% of diagnoses changed) Fewer failed or unnecessary treatments Cancer drugs 10% effective; rewarded failure with more revenue Prevent/maintain health versus treat (or treat earlier in progression) Need to organize around getting to better health, not treatment/“doing stuff” You shouldn’t have to pay more for excellent quality (E.g., P4P) Good quality is usually less costly – the cheapest option is to be healthy Ability of quality to drive costs greater in health care than any industry I have encountered
No group learning in “teams” of this sort. Improvement
Switch clinical judgment and satisfaction
Often reporting the wrong information with the wrong focus/wrong units of measurement Have to measure outcomes and ultimately costs and prices Value makes access relevant Value drives equity Failure to measure value is self-inflicted wound Brings on micromanagement, loss of autonomy
Set of outcomes Best outcome measures in the past have resulted from government action Cardiac: 41% reduction in mortality, first four years (CABG) IVF care What you measure matters, and affects results More than one measure Patients will benefit even if they don’t use measures Patients will use eventually Charge medical societies Date certain; otherwise government will convene groups to determine
KFSYSCC cited stage and co-morbid conditions (including COPD, and coronary artery disease etc.) as candidates to inform risk adjustment TNM Staging: Breast Cancer Primary tumor (T): TX: Primary tumor cannot be assessed. T0: No evidence of primary tumor. Tis: Carcinoma in situ (DCIS, LCIS, or Paget disease of the nipple with no associated tumor mass) T1: Tumor is 2 cm (3/4 of an inch) or less across. T2: Tumor is more than 2 cm but not more than 5 cm (2 inches) across. T3: Tumor is more than 5 cm across. T4: Tumor of any size growing into the chest wall or skin. This includes inflammatory breast cancer. Nearby lymph nodes (N) (based on looking at them under a microscope): NX: Nearby lymph nodes cannot be assessed (for example, removed previously). N0: Cancer has not spread to nearby lymph nodes. N1: Cancer has spread to 1 to 3 axillary (underarm) lymph node(s), and/or tiny amounts of cancer are found in internal mammary lymph nodes (those near the breast bone) on sentinel lymph node biopsy. N2: Cancer has spread to 4 to 9 axillary lymph nodes under the arm, or cancer has enlarged the internal mammary lymph nodes. N3: One of the following : Cancer has spread to 10 or more axillary lymph nodes. Cancer has spread to the lymph nodes under the clavicle (collar bone). Cancer has spread to the lymph nodes above the clavicle. Cancer involves axillary lymph nodes and has enlarged the internal mammary lymph nodes. Cancer involves 4 or more axillary lymph nodes, and tiny amounts of cancer are found in internal mammary lymph nodes on sentinel lymph node biopsy. Metastasis (M): MX: Presence of distant spread (metastasis) cannot be assessed. M0: No distant spread. M1: Spread to distant organs is present. Estrogen & Progesterone receptor status can matter because if receptors are present, a response to hormonal therapy is possible.
Innovations are now often discouraged Treatment-based, service-based reimbursement penalizes innovative providers (less complex DRG Revenues can go down faster than costs Current view is that high-tech raises costs. In value-based competition with results measurement, it will not Organizational and process innovation is really crucial, not just technology. Problem with technology-driven cost increases comes from deploying technology piecemeal Cleveland Clinic M.D. Anderson In most medical conditions today, there is now some way to address them. Most innovation will reduce costs from the cycle perspective going forward. Example – Diabetes In the current system profits from acute treatment have to be used to subsidize prevention such as podiatry Providers should be rewarded for success, not failure – right now care improvements lead to reduced reimbursement DRG system is 15% of the way Now contracting for full care cycles in organ transplants; future of health care
The market system not the problem, it’s the kind of market we’ve created Disconnect: pay for services; shifting costs; capturing bigger share of revenue
