Statement of the Problems
Health care is a “life and death” matter. Millions of Americans do not have health insurance and countless others are under-insured. Quality is mediocre and costs have soared out of control. There are no adopted national standards, precious little oversight and weak accountability.
Many American families have fallen into bankruptcy due to catastrophic health care expenses. Sky rocketing health care costs threaten to place the entire United States economy at risk. CMS (Centers for Medicaid and Medicare Services) released a report on July 28, 2011 that projects national health care costs will increase from $2.6 trillion in 2010 to $4.6 trillion in 2020. Health care will represent about 1 of every 5 dollars spent in 2020. Clearly, improving quality and controlling costs in the health care arena should be everybody’s business.
On March 18, 2009, Carolyn Clancy, Director of AHRQ (Agency for HealthCare Research and Quality) spoke before the U.S. Senate Subcommittee on Finance. In her remarks, Dr. Clancy began by stating the AHRQ mission: to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. She then defined health care quality as “getting the right care to the right patient at the right time --- every time”.
Dr. Clancy explained that, currently, the U.S. is severely lacking in its ability to get the right care to the right people at the right time, notwithstanding the fact that the United States leads the world in biomedical advances and innovation. Dr. Clancy suggested that the reason for quality and performance shortfalls is that “we have not yet designed systems to make the right thing easy to do”. To underscore the scope of the problem, she referenced a Rand Corporation study that found that Americans received recommended care only 55% of the time.
Further illustrating this continuing national health care cost/quality crisis is an article in the New England Journal of Medicine of January 10, 2010, which noted that in 2006 the United States ranked number 1 only in health care spending. The U.S. ranked 39th in infant mortality, 43rd in adult female mortality and 42nd in adult male mortality. In June 2010, the Commonwealth Fund, a private foundation that aims to promote a high performing health care system, published a study that identified the U.S. Health system as the most costly in the world; one which “consistently under¬performs on most dimensions of performance, relative to other countries”. The report compared the U.S. with six other nations --- Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom --- and concluded that the U.S. health care system “ranks last or next-to-last on five dimensions of a high performance health system: quality, access, efficiency, equity, and healthy lives”.
Clearly, the U.S. health care system does not appear to be all that well focused on either health or care and this must change.
The Achievable Health Care Plan --- A Viable Solution
I would like to present my hypothetical health care plan. It focuses on improving health care quality --- one patient and one service at a time. I call it the Achievable Health Care Plan (AHCP). It provides a system model that will make it easier to do the right things.
At the hypothetical Achievable Health Care Plan, day to day operations are driven by individual patient needs and recommended or required services. The goal is to provide every plan member with “just in time goods and services”. The flip side of this goal --- the need to avoid all unnecessary, wasteful or fraudulent services --- is equally important.
Early on, AHCP recognizes that a comprehensive system with both human and automated elements would be required to assist, inform, monitor, and oversee the process of moving toward a state of “total quality health care”.
Consequently, AHCP commissions a work group, the “Total Quality Healthcare Task Force”. It is includes a cross section of AHCP employees and board members, along with providers, community representatives and plan members. The task force then formulates an Information and Performance Management System (IPM).
The IPM intervention model that the task force designs is intended to:
• Dramatically improve performance by focusing on traditionally under-attended areas, including point-of-service management and information control functions
• Assist in maximizing “just in time” service delivery
• Capture and process information to develop and refine treatment guidelines, rules and regulations
• Provide point of service decision support assistance to both providers and patients
• Identify unnecessary or inappropriate services
• Uncover fraud and abuse
• Evaluate both provider and health plan performance
• Support evidence based medicine, evidence-informed health care policies and best practices
The AHCP task force correctly elevates information to equal status with performance because these two critical “joined at the hip” elements, in a total quality care continuum, both feed and reflect each other. Shortcomings in either will stand in the way of improving health care quality and eliminating waste.
At the individual patient level, complete and accurate health care data is essential. It is needed to identify required but undelivered services, to uncover and avoid duplicate or unnecessary services, and to develop personal health care profiles that assist health care delivery personnel and patients make holistic treatment decisions and avoid medications and/or other medical interventions that might be harmful.
At the payer and national levels, complete and accurate health care data will provide the foundation for research and standards development, for quality measurement and assurance, and for cost controls, performance measurement and productive and technical efficiency.
While there are presently no formally adopted national standards, many years of study and research have produced a number of national quality measure sets. Notable among these are HEDIS (Health Effectiveness Data and Information Set) from NCQA (National Committee for Quality Assurance) and PCPI measures from the Consortium for Performance Improvement via the American Medical Association (AMA). The AHCP task force recognizes the importance of evaluating the appropriateness and validity of important quality measures. Therefore, AHCP selects a series of treatment quality measures, and puts in place a constrained effort to maximize their delivery, while, at the same time, comparing both health and cost outcomes for those patients who received them versus those who did not. The plan is to gradually add additional measures over time in order to broaden the scope of the information and quality improvement process.
The initial batch of measures is selected taking into account the following:
• Measures associated with high incidence illness or disease categories
• Measures associated with high cost categories
• Measures characterized by recent performance short falls
• Measures for which direct or indirect financial incentives were available
AHCP understands that, typically in the industry, performance measurement information is not disseminated until 3 to 15 months after services are delivered. Not only has the trail gone cold by the time formal reporting and analysis becomes available, but arguably more importantly, data and information continuums are usually not designed to promptly monitor and influence individual patient care. It is important to have systems available to directly encourage and facilitate that Billy receives his immunization, Sarah has her mammogram and George gets the proper treatment and medication for his diabetes --- and that all of these and other preventive and treatment services are delivered in a timely manner.
Data and treatment management functions are more timely and effective as they get closer to the point of service. Until now, approaches to performance improvement have typically focused on the past. In contrast, IPM promotes behavioral changes and performance improvements in the delivery and reporting of health care goods and services by using automated solutions that provide for information-to-action time cycle acceleration and lead to significant reductions in information leakage. Embedded information integrity functions address information accuracy and completeness and provide a special emphasis on protecting data as it travels between systems and organizations.
The Achievable Health Care Plan IPM strategy introduces methods to maximize timely delivery of required and recommended services. Rules driven analytical capabilities are built into the information and service management continuum to inform and influence improved treatment and reporting. This accelerates the health care performance time cycle so that treatment reporting, support, influence, and response elements can be available either at, or as close as possible, to the point of service. This rapid response intervention approach leads to improved compliance with clinical service standards, and more complete and comprehensive healthcare services to patients. This results in improved patient and population health in addition to cost savings and improved efficiency.
At the heart of the AHCP Information and Performance Management continuum is a software application called HIPE (Healthcare Information and Performance Engine). HIPE is a configurable rules-based software system that is designed to both inform and influence the timely delivery of required services. HIPE also serves as a vehicle to exploit and/or verify the widespread belief that the timely delivery of necessary services will both improve health status and reduce costs. HIPE is both a traffic cop and a detective, and each day HIPE goes about the business of monitoring, influencing, evaluating and reporting activities and trends with the goal of moving gradually but surely in the direction of total quality health care.
A day in the life of HIPE should serve as an excellent window into the nature and status of the IPM journey at the hypothetical Achievable Health Care Plan.
It is 12:01 AM at AHCP and HIPE begins a new and very busy day!
------- To be continued. Next week, Episode Two: Healthcare Information and Intervention at the Speed of Need
