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by Thomas Graf
Accountable care, population health, value-based payment, etc. Every day we are faced with ever more jargon associated with the incredible upheaval in the delivery and financing of healthcare.
Our ability to digest each of these new ideas and deliver better "value"--as defined by lower cost and higher quality--is stressed beyond belief. Adding to the confusion is the need to verify the definition of each of these since the meanings remain fluid.
The true underlying issue is what we have been grappling with in the United States for several decades: that we currently deliver unreliable healthcare inconsistently, but at a very high cost. The leads to frustratingly variable results for patients, medical professionals and payers. We have seen this before, of course, and many are sanguine about the difference this time around.
This time we have the ability, albeit incomplete, to granularly define and measure quality. This is key. Without the numerator in the value equals quality over cost equation, you cannot measure value. Without value, being accountable is impossible, leaving only cost. Managing cost was the Achilles heel the last time.
With quality defined and measured, we can become accountable for the delivery of value and we can compare the value created from one to another, and we can improve. Most importantly, with quality defined, we can leverage quality improvement to drive down the total cost of care.
This is another fundamental difference between now and previous attempts. The concept that high quality and low cost not only can but do coexist is critical. This creates a critical alignment of the medical professionalâ€™s goal, patientâ€™s goal and society's goal of high-value healthcare.
Numerous examples from Geisinger Health System in Pennsylvania illustrate the power of this in improving the care of patients, as well as the engagement of patients and medical professionals. Geisinger has been successfully re-engineering the care for various groups of patients for the last decade. Our expanded medical home model has been driving quality improvement to lower total cost of care and improve patient and professional experience.Our hospital-based redesign has been reducing mortality and length of stay for various hospital-based specialties, as examples.
Current work focuses on understanding the optimal organization and sequencing of services to further enhance the value produced by improving quality and reducing cost. Each of these focuses on different areas and encounters unique challenges in the value re-engineering of the total care of patients. Linking all of these elements together is required to realize the vision of accountable care and enhanced value.
The need to embrace the Institute for Healthcare Improvement "Triple Aim" is core, but added to it is the need to enhance medical professional experience. With proper attention and focused effort, consistent success can be achieved.
Many are currently attempting this kind of work with 23 Pioneer accountable care organizations, 114 Medicare Shared Savings Program (MSSP) ACOs starting in 2012, 106 ACOs starting in 2013 and hundreds of Center for Medicare & Medicaid Innovation Bundled Payments for Care Improvement (BPCI) participants. Predictably, many of these will not succeed because systematic redesign is difficult and achieving highly reliable delivery of this measurably better care is even more challenging.
The combination of a dedicated team, diligent effort, a proven roadmap and systematic provision of care is critical. The care should be physician-directed, but team-delivered and tailored to the specific needs of the patient, steeped in all available literature-based evidence and patient-derived preferences to create that consistent success. In an effort to help others, we will review some of our successes in the coming months.
Thomas Graf, M.D., is chief medical officer for population health at Pennsylvania's Geisinger Health System. He is responsible for the value re-engineering of the care continuum and other population health initiatives for Geisinger, including the ACO portfolio and with CMS, the Physician Group Practice Transitions Demonstration and Bundled Payments for Care Improvement.
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