This is going to be a big year - healthcare needs more change and innovation than ever! So one of my resolutions is to do more regular blogging. I will likely move to shorter blogs about news stories of interest, with a plan to distill them down to points which will be relevant to those interested in promoting innovative thinking and action in healthcare.
I'm going to start with two new stories that are more related than one might think - one on healthcare value, the other on snow removal.
How Measuring Outcomes Drives Innovation
I just read Michael Porter's latest NEJM essay entitled, "What is Value in Healthcare?". The key points are:
1. We need to base our reimbursement system on Value (Outcomes/Cost) not Volume. In 2009, Porter described this in more depth in his NEJM article "A Strategy for Health Care Reform — Toward a Value-Based System".
2. Measuring real outcomes is critical (what really happens to the person, not simply their lab values or process followed). For example, for a diabetic - real outcomes are whether someone loses their sight, needs to go on dialysis or has a heart attack (not what their HbA1C value is and how often it is checked). He defines these in an "Outcome Measures Hierarchy" that involves three tiers: Tier 1 (Degree of Recovery), Tier 2 (Time to Recovery) and Tier 3 (Sustainability of Recovery). This spectrum is what we really care about and encompasses both short and long-term outcomes, as well as "cycle time" (how quickly one gets to recovery).
3. The main purpose of measuring actual outcomes is to enable "innovations in care". He describes how measuring, reporting and comparing these actual outcomes are what allows us to think and act in innovative ways.
Dr. Thomas Lee follows up on Porter's essay with his own complementary one: "Putting the Value Framework to Work". He says, "When measurement is oriented toward what happened to patients instead of what services were performed, interesting challenges and opportunities arise." For example, he notes that their typical PCP reports included data on number of office visits and RVUs, but not on the number of ER visits and hospital re-admissions, nor on the cycle times for how quickly discharged patients are seen in follow up clinic. Dr. Lee also notes that "just the collection of such data requires organizational change and the weakening of walls between our silos", (which I assume he means is a good thing!). He notes that his system (Partners) is currently working on creating "value dashboards" for issues such as stroke, diabetes and colon cancer. They will identify "pause points" in patients care and define what should be routine at those points via checklists. That is basically what we have been developing with our Process Checklist System (we call them "Pathways") - for things like new diagnoses of Hematuria, Afib and Cancer - so I am a big can of that concept!
Paying plows by inch, not hour, can save a city’s snow budget (link to story)
The second story which caught my attention was an NPR interview I heard with the Mayor of small town in Massachusetts... and how they saved time and money by creating a value based system for snow removal. Apparently, the typical reimbursement mechanism for snow removal has been to pay for the amount of time to remove snow ("hourly rate"). Thus the incentive for truckers has been to go slow so they can charge more. The Mayor of Quincy changed the incentive to paying by the inch. The result is that they saved money AND the snow was removed more quickly! Yep - just common sense, and something that I'd like to see more of in the healthcare system as well!!!