In the ongoing search for new ways to cut costs while improving healthcare, researchers at the University of Utah Health Care system have developed a program correlated with better patient outcomes in three common procedures that also trimmed costs by up to 11%. They published their findings Tuesday in JAMA.
In the program, a value-driven outcomes tool integrated data on spending and health outcomes for three clinical areas, analyzing the information to determine exactly what elements in a procedure—say, a bandage—cost how much. It also broke down costs and outcomes by physicians, who were given access to this information.
The study measured quality and patient outcomes relative to cost from 2012 to 2016 at University of Utah Health Care in three clinical areas: total joint replacements for hips and knees, hospitalist laboratory utilization and sepsis management. After baselines in outcome measures were established for each of those areas, care processes were redesigned and quality improvement projects launched. Variations in costs and outcomes served as prime opportunities for improvement.
When the researchers re-evaluated those clinical areas, they found direct costs had been reduced and outcomes generally improved. But, the study also warned, “causality cannot be established” because the clinical improvement studies' designs generally lacked concurrent control groups and statistical adjustment for potential confounding factors.
Still, with joint replacement, direct costs fell by 7% and 11% during the first and second evaluation years, as compared to the baseline period. The mean length of stay also fell from 3.5 days to 2.88 during the second year, after the schedules of the hospital's physical therapists were shifted. The shorter length of stay accounted for 34% of the cost reductions between the baseline and second evaluation year.
After hospitalists started their quality improvement project, the mean daily cost and utilization of laboratory tests fell, saving the hospital more than $250,000 annually. The risk of being readmitted to the hospital within 30 days also dropped slightly, from 14% to 11%.
A few elements were critical to the success of the value-driven outcomes program, said Dr. Robert Pendleton, a senior author of the study who is also a hospitalist and chief medical quality officer at the University of Utah Hospital and Clinics. One was that it treated physicians as partners in the drive to reduce costs.
“As long as they're assured that they have a similar and equal opportunity to improve quality, our experience is that they'll be drawn in and will want to drive improvement,” said Pendleton, who as a hospitalist had his own laboratory utilization rates compared with those of his peers under the program. “You really need to be able to put the data in the context of a culture that embraces that peer-to-peer transparency,” he added. “If you can create that culture ... you can really unlock some of that motivation, passion and innovative spirit of doctors.”
The characteristics of the data that the tool used—cost of care, rather than charges and claims, and at the level of the patient rather than a department or service line—also made a difference, Pendleton said. For doctors, that information translated into understanding how decisions for individual patients affected outcomes and care delivery overall.
But if the University of Utah's experience highlights the promise of value-based care, it also underscores many of its challenges. And to what extent the tool, or others like it, could be replicated in other health systems remains a key question.
The study acknowledged numerous limitations of the value-driven outcomes approach. The data and tool were limited to University of Utah Health Care and did not take into account pharmacy, laboratory and imaging services outside its walls, for instance. Publicly reporting outcomes and costs could also motivate clinicians to avoid caring for riskier and more costly patients, it warned.
“There is also a need to further demonstrate the generalizability and scalability of the value-driven outcomes approach across many more conditions and units, both at the University of Utah and at other healthcare systems,” the study added.
In an era where physicians frequently suffer metric fatigue, asking them to participate in yet another program rife with measurement can be another challenge.
“The reality is that providers in today's healthcare are being asked to take on an unprecedented amount of complexity,” Pendleton said. By giving physicians cost information, the value-driven outcomes program sought to tap into physicians' inherent altruism and motivation to do right by their patients, but the response has been varied, with some groups more enthusiastic than others, he added.
“We are still working to that end,” Pendleton said. “But it's hard. This work is not easy and not fast.”
