Some evidence is emerging from states such as California showing that health plans associated primarily with more integrated delivery systems generally have higher quality scores without using more resources than less-integrated models, such as the preferred provider organizations typically associated with narrow networks. Given such interplay among the three pillars of healthcare reform, how can waste be eliminated and greater value be created?
A partial answer lies in recognizing the need for innovation across all of those pillars. Lessons from behavioral economics can be used to design benefit packages that reward consumers for seeking early preventive care, and penalize them for seeking treatments for which there is little or no evidence of value. On the payment front, the CMS and the private sector are experimenting with a variety of approaches, including penalties for readmissions, bundled payments for selected conditions and various degrees of capitated payments and global budgets. While coverage and payment reform can provide the foundation for eliminating waste and creating greater value, the bulk of the work must be done by the delivery system.
The greatest opportunity to eliminate waste and create greater value is at the nexus of where physicians and other providers engage patients. This is the heart of clinical integration—defined as the extent to which the care provided is coordinated across conditions, visits, providers and settings over time. This process needs to be studied to root out waste, eliminate complexity in steps that do not add value, and identify the “value leakages” that occur particularly during the hand-off stage from one provider to another or from one setting to another.
There is a natural human tendency to look for simple solutions to problems. Healthcare is no different. The field abounds in innovations including new drugs and devices, health coaches, same-day scheduling systems and use of mobile devices. Healthcare innovation centers have sprung up around the country—many associated with leading integrated delivery systems—that are working on developing new approaches to delivering more cost-effective care. Too often, however, these are centered on a single one-off innovation to solve a problem that is not amenable to a single approach.
Complex problems require several interdependent innovations that re-inforce each other, called “packaged innovations.” They must be developed and implemented as a package or group to achieve impact.
For example, a program designed to work with patients who have difficulty keeping their Type 2 diabetes under control might combine a diabetes nurse educator with patients having access to their electronic health record through a patient portal along with a receptionist who has a target list of patients for follow-up phone calls using a pre-populated disease registry. The package increases the chances for success compared with only hiring a diabetes nurse educator.
Our healthcare system will need to continuously innovate to incorporate desired new advances in biomedical technologies and fulfill the promise of precision medicine within the continuing pressure to restrain the growth in costs. This will require the use of high-octane packaged innovations that strike at the roots of waste and that facilitate evidence-based care provided through technology-enabled healthcare teams to create greater value for patients.