The U.S. healthcare system operates like an ATM machine that takes days to release cash. It functions like a home construction project whose carpenters and plumbers use different blueprints. And it does business like a store that prices items depending on who is making the purchase.
It fails to contain wasteful spending, estimated at about $765 billion in 2009 alone, largely from unnecessary and inefficiently delivered services, excess administrative costs and overpricing, and in fraud and missed prevention opportunities.
Those are some of the findings from a 382-page report the Institute of Medicine released Thursday calling for a major overhaul to remove inefficiencies and other barriers to quality care.
The report, "Best Care at Lower Cost: The Path to Continuously Learning Health Care in America," was prepared by a 17-person committee chaired by Mark Smith, President and CEO of the California HealthCare Foundation.
"We tried to address a big-deal problem in a way that is very comprehensive, because we feel much of what has been said to this point has been in bits and fragments," says Gary Kaplan, MD, a member of the authoring committee as well as Chairman and CEO of Virginia Mason Health System in Seattle. Providers, payers, patients, funders, the government—everyone—has to see quality, outcomes, technology, fraud and waste in a holistic fashion.
Kaplan adds that the committee hopes "that the first thing to come from this is awareness. Too many providers are saying to themselves, 'We're alive and well; we know change is coming, but we're banking that change will be glacial, so we don't have to do much right now. We're profitable.' "
A case in point is the transition to electronic health records and the attainment of meaningful use attestation. While some providers may see these moves largely as big expenditures, for which they may recoup some federal incentive payments, they may overlook the enormous potential of using EHRs to gather real-time data on inappropriate, unnecessary or incorrect use of expensive hospital resources.
"We can know for the last 100 patients who had X procedure, we have this percent of complication. We know that in real time, not through 18-month-old data. This is not an abstraction, and can provide us with early warning signs and places where we may intervene."
The report issues 10 recommendations to improve quality of care, and use healthcare resources better. They are:
1. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement and the generation of new knowledge.
To this end, the report says hospitals and clinicians should "employ digital systems that capture patient care experiences reliably" and implement practices and standards for better data interoperability. The federal National Coordinator for Health Information Technology, software developers, and standards organizations should make sure that their systems support better care, system improvement and new knowledge.
2. Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge.
The report suggests that the Secretary for Health and Human Services, should examine the Health Insurance Portability and Accountability Act and institutional review board policies for any perceived or actual restrictions on the use of clinical data to gain knowledge that advances science and care improvement. Consumer groups, professional societies, researchers and grantmakers should help develop strategies to improve understanding of the benefits and importance of accelerating use of clinical data to improve care and health outcomes.
3. Accelerate integration of the best clinical knowledge into care decisions.
The authors explained that they want research, advocacy, specialty and care delivery organizations to use evidence-based and "harmonized" clinical practice guidelines.
"Public and private payers should promote the adoption of decision support tools, knowledge management systems, and evidence-based clinical practice guidelines by structuring payment and contracting policies to reward effective, evidence-based care that improves patient health," they said.
4. Involve patients and families in decisions regarding healthcare tailored to fit their preferences.
Patients and their families should expect to fully participate in their own care, and clinicians should use informed share decision-making tools. Federal agencies, including the Centers for Medicare and Medicaid Services, should promote and measure patient-centered care through payment models, contracting policies and public reporting programs.
5. Promote community-clinical partnerships and services aimed at managing and improving health at the community level.
Public and private payers should incorporate population health improvement efforts into payment and contracting policies, and measure accountability.
6. Improve coordination and communication within and across organizations.
Health economists, researchers, professional specialty societies should develop and test metrics to monitor care transitions to make sure they improve patient outcomes.
7. Continuously improve health care operations to reduce waste, streamline care delivery and focus on activities that improve patient health.
CMS, the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Research Institute, quality improvement organizations and improvement leaders should develop a learning consortium that improves effectiveness and efficiency of care. Additionally, organizations should find methods to remove unnecessary burdens on clinicians and staff.
8. Structure payment to reward continuous learning and improvement in the provision of best care at lower cost.
Public and private payers should move to outcome and value-oriented models of payment that draw on payment incentives.
9. Increase transparency on healthcare system performance
Public and private payers should promote transparency in quality, value and outcomes to aid care decisions.
10. Expand commitment to the goals of a "continuously learning" healthcare system.
Healthcare organizations should "develop organizational cultures that support and encourage continuous improvement, the use of best practices, transparency, open communication, staff empowerment, coordination, teamwork, and mutual respect and align rewards accordingly," the authors wrote.
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