Like politics, all healthcare is local, and that's why during this political season in Washington, it's worthwhile to observe local laboratories where reform happens every day.
Quality, cost-cutting experiments abound in cities, regions
That's what took me to Madison, Wis., recently, where the Wisconsin Collaborative for Healthcare Quality brought together a diverse group—physicians, hospitals, health plans and employers—to work on a critical issue: How can we get better value from the $2.3 trillion the U.S. spends annually on healthcare?
The collaborative is a leader in improving quality and cost-effectiveness. I watched as it bit off a small part of the problem: to see if doctors, insurers, employers and quality-measurement experts could begin combining numbers on quality and cost to measure efficiency in a way that would help providers deliver better care at lower cost and help payers make better purchasing decisions. Anyone who has followed such discussions knows they can be contentious, but this one was civil and productive, with clear recognition that the participants can set an example for the nation's healthcare system.
No matter what happens in Washington, it will require efforts like these to tackle the inefficiencies in our system, which by some estimates account for nearly one-third of all spending. Without better tools to measure and reduce waste, policymakers cannot extend care to millions of Americans who go without.
The collaborative is one of 15 state- or community-based organizations working with the Robert Wood Johnson Foundation's Aligning Forces for Quality, also known as AF4Q, initiative launched in 2006. AF4Q joins those who get care, give care and pay for care to lift quality and efficiency in their communities. Our hope is not only to bring lasting change to the 15 markets but also to develop national models for reform.
The heart of the program is a three-pronged effort to improve quality of care in doctors' offices and hospitals; to measure and publicly report on the quality of care; and to engage consumers in making informed choices about their health and healthcare. We are also working to reduce racial and ethnic inequities in care and enhance the role of nursing.
In some communities, uniting consumers, doctors, hospitals, insurers and employers was a feat in itself. Consider, for instance, the Puget Sound Health Alliance in Seattle. In business since 2004, the alliance considered its first victory the simple act of bringing together diverse stakeholders—many of whom had never sat at the same table—around a common goal of improving health and healthcare. It was especially important for companies that buy health insurance for their employees to sit down with the doctors. For many, it was the first time they didn't have to speak with each other over the head of an insurance company.
Over time, the group found it was easier to forge agreements at the local level than at the state or federal levels. With support from AF4Q, the group published three Community Checkup reports on healthcare quality in the Seattle region, using 21 measures ranging from whether diabetes care was adequate to whether patients with lower back pain were getting unnecessary imaging.
Key to putting together the Seattle group was Ron Sims, at the time the executive of Washington's King County (and now in the Obama administration), who used his clout to get competing interests to come together.
Federal policymakers cite potential savings from preventing avoidable hospital readmissions. The Community Health Alliance of Humboldt-Del Norte is working on this in California. Nurses help keep patients from being readmitted to the hospital by making sure these patients follow their prescribed care after treatment. Innovations like these have cut readmission rates substantially—to 8% from 10% in the first year.
Or consider a groundbreaking initiative to ask patients about their doctors. Two of the 15 AF4Q groups, the Kansas City Quality Improvement Consortium and the Healthy Memphis Common Table, joined Consumers' Checkbook/the Center for the Study of Services in a pilot program to survey patients on the care they receive.
This wasn't just patients complaining about whether the chairs were comfortable at their doctor's office. The survey asked questions developed by the U.S. Agency for Healthcare Research and Quality and endorsed by the National Quality Forum, such as how well the doctor listens and how easy it is to get an appointment. Studies show there is a relationship between what patients say about their care in this carefully designed survey and their doctors' clinical outcomes. It differs in important ways from the types of open-ended user surveys (restaurant-rater Zagat, for instance, is doing one of these) that can antagonize doctors, who denigrate them as popularity contests.
The communities defused criticism by rating a doctor only on a sufficient number of responses. In Kansas City, for example, the sample was 58 patients per doctor for more than 700 doctors. And doctors could review the ratings before the information went online. You can see the results for both communities and Denver (the third participant) at checkbook.org/patientcentral.
For more information on reforms occurring right now in communities across the country, even as Congress debates overhauling the system, go to forces4quality.org.
Anne Weiss is team director of the Robert Wood Johnson Foundation's Quality/Equality Healthcare Team and a senior program officer.
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