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Today, 21st century medical technology is often delivered with 19thcentury organization structures, management practices, measurement, and pricing. Universal coverage and access to care are essential, but not enough. The core issue in health care is the value of health care delivered.
Significant improvement in value will require fundamental restructuring of health care delivery, not incremental improvements. -Process improvements, care pathways, lean production, safety initiatives, disease management and other overlays to the current structure are beneficial but not sufficient.
Aligning Competition with Value
Competition for patients/subscribers is a powerful force to encourage restructuring of care and continuous improvement in value. Today's competition in health care is not aligned with value. The financial success of system participants is not equal to patient success. Creating positive-sum competition on value is a central challenge in health care reform in every country
Principles of Value-Based Health Care Delivery
The central goal in health care must be value for patients, not access, equity, volume, convenience, or cost containment
Value=Health outcomes/Costs of delivering the outcomes
Outcomes are the full set of patient health outcomes over the care cycle. Costs are the total costs of care for the patient's condition, not just the cost of a single provider or a single service. Quality improvement is the key driver of cost containment and higher value, where quality is health outcomes. Better health is the goal, not more treatment. Better health is inherently less expensive than poor health
Benefits are Prevention, Early detection, Right diagnosis, Right treatment to the right patient, Early and timely treatment, Treatment earlier in the causal chain of disease, Rapid cycle time of diagnosis and treatment, Less invasive treatment methods, Fewer complications, Fewer mistakes and repeats in treatment, Faster recovery, More complete recovery, Less disability, Fewer relapses or acute episodes, Slower disease progression, Less need for long term care, and Less care induced illness
Value-Based Health Care DeliveryThe Strategic Agenda
Organize into Integrated Practice Units around the Patient's Medical Condition (IPUs)
Including primary and preventive care for distinct patient populations
Measure Outcomes and Cost for Every Patient
Most providers track charges not costs. Most providers track cost by billing category, not for medical conditions. Most providers cannot accumulate total costs for particular patients. Most providers use arbitrary or average allocation of shared resources, not patient specific allocations.
Cost should be measured for each patient, aggregated across the full cycle of care. Cost should be measured for each medical condition (which includes common co-occurring conditions), not for all services. The cost of each activity or input attributed to a patient should reflect that patient's use of resources (e.g. time, facilities, service), not average allocations. The only way to properly measure cost per patient is to track the time devoted to each patient by providers, facilities, support services, and other shared costs.
Move to Bundled Prices for Care Cycles
Bundled Payment is total package price for the care cycle for a medical condition. It includes responsibility for avoidable complications. The medical condition capitation, the bundled price should be severity adjusted.
Integrate Care Delivery Across Separate Facilities
Deliver services in the appropriate facility, not every facility.Excellent providers can manage care delivery across multiple facilities in multiple geographic areas
Grow by Expanding Excellent IPUs Across Geography
Create an Enabling Information Technology Platform
Utilize information technology to enable restructuring of care delivery and measuring results, rather than treating it as a solution itself. Common data definitions. Combine all types of data (e.g. notes, images) for each patient over time. Data encompasses the full care cycle, including referring entities. Allowing access and communication among all involved parties, including patients. Structured"data vs. free text. Templatesfor medical conditions to enhance the user interface. Architecture that allows easy extraction of outcome, process, andcost measures. Interoperability standards enabling communication among different provider systems
Care Delivery Value Chain
Illustrative Implications for HIV/AIDS Care
Targeted prevention for at-risk individuals creates more value than across the board efforts. Early diagnosis helps in forestalling disease progression. Intensive evaluation and treatment at the time of the diagnosis can forestall disease progression. Improving compliance with first stage drug therapy lowers drug resistance and the need to move to more costly second line therapies. Screening is most effective when integrated into a primary health care system.
Providing maternal and child health care services is integral to the HIV/AIDS care cycle by substantially reducing the incidence of new cases of HIV. Community health workers can not only improve compliance with ARV therapy but can simultaneously address other conditions.
Illustrative Implications for HIV/AIDS Care
Community health workers can have a major role in overcoming transportation and other barriers to access and compliance with care. Providing nutrition support can be important to success in ARV therapy. Integrating HIV screening and treatment into routine primary care facilities can help address the social stigma of seeking care for HIV/AIDS. Gender dynamics limit the use of some prevention options in certain settings. Management of social and economic barriersis critical to the treatment and prevention of HIV/AIDS.