We have higher preventable deaths than in other countries. If you look at treatable deaths, the US does worse than comparable countries and this difference is only worsening. Health care costs in relation to gross domestic product (GDP) are higher than in other countries and are worsening with time. So, we are getting worse quality at higher costs.
Value is often measured by costs as costs are easier to control. Dr. Penson provided this list of the drivers of healthcare costs in the US; inadequate prevention, behavioral factors, chronic illness, aging populations, racial/ethnic make-up, high cost of drugs and medical devices, insurance administrative costs, end of life care, etc. But Dr. Penson feels one of the biggest drivers is “fee-for-service medicine” – we are paid more for doing more. He cited the O'Neil study (2016-JNCI) on bladder biopsies. In 2004, Medicare decided to drive bladder biopsies from the hospital to the office setting by increasing the reimbursement for office-based biopsies. This change increased the number of biopsies being performed in the office but there was no decrease in the number of biopsies performed in the hospital. So, the cases were not moved, urologists just did more bladder biopsy cases because urologists got paid more. And this increase in bladder biopsies did not yield an increase in bladder cancer cases.
So, one way to get away from volume (which yields more reimbursement) is to move towards value and accountability. Dr. Penson explained Porter and Lee’s 6 strategies for improving value in healthcare around primary care:
Porter ME, Pabo EA, Lee TH. Redesigning primary care: a strategic vision to improve value by organizing around patients' needs. Health Aff (Millwood). 2013 Mar;32(3):516-25. doi: 10.1377/hlthaff.2012.0961
1. Organize into integrated practice units (IPU):
Fundamental restructuring of healthcare services around patients' medical conditions through the use of a dedicated multidisciplinary team of clinicians who devote a significant portion of their time to that condition. The team takes responsibility for the full cycle of care (outpatient, inpatient, rehab, etc.), IPU has a single administrative and scheduling structure and care is located in a dedicated facility. The team would have a clinical care manager and measure outcomes, costs, and processes. So, there is joint accountability accepted for outcomes and costs. This is now happening in academic medical centers.
2. Measure outcomes and costs for every patient:
Measure outcomes that matter to patients and this will go beyond measuring just mortality and morbidity. Previously, we focused on processes and guidelines, which Dr. Penson says is the wrong things to do, as a patient does not care about the AUA guidelines but they do care in having better outcomes. We need to track cost data by using time-driven activity-based costing.
3. Move to bundled payment for care cycles:
The care cycle is easy to define for acute medical conditions. For chronic conditions or primary care, a cycle is a defined period of time. So, payment is aligned with “what the team can control.”. These bundled payments must include: risk adjustment for disease severity, holding the provider responsible for avoidable complications, stop-loss provisions that mitigate the risk of unusually high-cost events, and mandatory outcomes reporting.
4. Integrate care delivery systems:
Develop multisite health organizations which are clinically integrated networks. These systems must make choices on defining the scope of the services which allows the system to eliminate service lines that are not of high value. The system must concentrate on volume in fewer locations and choose the right location for each service while integrating care across locations. Many academic medical centers and hospital networks are preparing and/or doing this.
5. Expand the geographic reach:
This needs to be done in a way that improves value as opposed to increasing volume. Services should not be duplicated. There are 2 models: 1) Hub-and-spoke model which is a primary medical center with satellite facilities that act as “feeders “as needed and 2) clinical affiliation which is when primary medical center partners with community providers, using their facilities rather than adding capacity and primary center provides management oversight of clinical care. Dr. Penson says this is what is being done at Vanderbilt which affiliates with community providers but does not own them.
6. Build an enabling information technology:
An IT system that is “useful in a meaningful way” helps different parts of the IPU work with each other, enables measurement, and facilitates novel reimbursement approaches. Dr. Penson noted there are 6 essential elements of a value-enhancing IT platform; patient-centered, common data definitions, encompasses all types of patient data, access to all parties involved in care including the patient (patient portals), includes templates and expert systems for each specific condition and architecture makes it easy to extract information.
There is a shift to new payment and delivery models that seek to shift risk to providers in an effort to improve the quality of care and decrease healthcare spending. These models are moving away from fee-for-service to paying “value over volume”. The provider is going to see more episodic bundles and capitation. Bundled payments are the core of this as it effectively capitates outpatient care by disease process and severity. Medicare has designed and implemented various demonstration projects and groups are proposing their own groupers. So, the future American Healthcare Reimbursement is a single payment of comprehensive care.
Presented by: David F. Penson, MD MPH, Hamilton and Howd Chair of Urology Oncology, Professor and Chair, Department of Urology, Vanderbilt University Medical Center, Nashville, TN
Written by: Diane K. Newman, DNP, CRNP, FAAN, BCB-PMD, Nurse Practioner and Co-Director, Penn Center for Continence and Pelvic Health Adjunct Professor of Urology in Surgery during the 2021 Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU) Winter Meeting.