If you had to guess how the United States ranks among 11 industrialized countries on measures of health system quality, efficiency, access to care, equity, and healthy lives, what would you say?
Unfortunately, the U.S. would flunk the “you get what you pay for” test. The U.S., which ranked dead last, stands out as having the highest costs and lowest performance; the U.S. spent $8,508 on health care in 2011, compared with $3,406 in the United Kingdom, which ranked first overall, according to The Commonwealth Fund.
New evidence is emerging that may help those of us who are working to spend our limited resources by investing in new care models and integrating providers with each other in networks that offer high quality low cost care. Like with any important test, the pressure is on to reduce costs and improve performance.
Recent evidence offers some opportunities for focusing investments. The payment reform paradox states that savings for payers are revenue losses for providers. A number of efforts at payment reform are in play.
For example, of the 114 Accountable Care Organizations (ACOs) that participated in the Medicare shared savings program in 2012 half achieved savings, but only 29 achieved enough savings to receive the economic benefit themselves, rather than the savings staying with Medicare.
A recent analysis of bundled payments concludes that the case for benefit is reasonably compelling for Medicare patients, but it is much weaker for commercial payers. And among Medicare recipients, the greatest variation in the cost of care is the variation in post-acute care. However, achieving success with bundled payments has proven to be extremely difficult and requires very high levels of clinical integration such as those that have been achieved at the Mayo Clinic and Geisinger. Smaller health systems with traditional disparate incentives and high variation in care patterns will find it more difficult to negotiate bundled payments and effectively distribute the bundled payments.
Another recent summary of how primary care can be redesigned to improve the value for patients suggests some radical redesign may be better for both patients and providers. In some diseases cared for by specialists, such as breast cancer, multidisciplinary teams built around the specific disease have been shown to improve outcomes and reduce costs.
Building on that model, authors Michael E. Porter, Erika A. Pabo, and Thomas H. Lee suggest a redesign of primary care is more effective when primary care is divided into subgroups – the authors recommend five – and build multidisciplinary teams around the specific needs of those patients. Two of the authors of this review practice in such settings. These subgroups are not based on individual diseases, but are based on similarities in the types of care needed, which reflect patients’ conditions and the severity of those conditions. Such redesign has implications for the composition of the teams, office layout, and aligning incentives.
For example, the authors propose that the patient centered medical home may be “necessary but not sufficient” for achieving real value. More segmentation is needed; they note our colleagues in the Mass General Physicians Organization have found that care managers coordinating care by telephone can work for elderly patients but is not very effective in younger patients living with chronic illnesses.
From this recent evidence, I’d suggest that community health systems like ours might benefit from investing in reduction in variation of post-acute care and primary care redesign, while negotiating contracts that allow us to meaningfully share in the resulting savings while improving care.
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