Split Decisions

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Even outcome measures tend to be narrow in focus, measuring the success of procedures, such as an operation. These measures can highlight errors and which patients live or die, but they don't get at the fundamental questions about performance and patient health. Did the full course of treatment improve the patient's overall health? Was the patient readmitted for any related complications or conditions? Where were the gaps in care?

"We need to really study how patients do across the continuum," says Michael Modic, MD, chairman of the Cleveland Clinic Neurological Institute. "You can't just look at it once; you have to look at how a patient does over time, and that means you need to look at how patients do across venues—outpatient, hospitalized inpatient, acute or subacute rehab, home care, and back to wellness and outpatient again."

The Cleveland Clinic Neurological Institute has begun this effort by working with a combination of general and disease-specific health status measures that are tracked longitudinally across the care continuum.

All patients may be assessed using general scales that measure depression, pain, or their level of activity after a care episode, for instance. But stroke patients are also assessed with the National Institutes of Health Stroke Scale or the modified Rankin Scale, both of which measure the degree of disability or dependence of stroke patients.

The measures are embedded in the patient's electronic health record and become a part of all future encounters, explains Modic. "Each time patients come, we continue collecting data. Now when they come to the Neurological Institute, there are measurements from before, and you can actually plot these and show the patient that these are objective scales to assess how you're doing with your disease."

Implementation wasn't easy, he says. Measuring and assessing health status adds about 10 minutes to the patient encounter, so physicians have had to change scheduling processes and workflow. But increased costs are worthwhile if they improve the value of healthcare, which is why cost measurements have to be coupled with health status measures, says Modic.

"The true definition of value is outcomes divided by costs," he says. "So if your outcomes go up and costs go down, your value goes up. That's a great equation in medicine because you may choose to increase your cost if it increases outcomes."

As the hospitals and other providers develop measures that really assess performance, they not only can get a better idea of physician performance and patient health, but they can make a more convincing case to patients, and even payers, about the quality of their care.

Preparing for a new system
While defragmenting the healthcare system may happen at the service line or disease line level through better management of episodes of care, the impetus for change will have to come from top hospital leaders, who are ultimately responsible for the alignment vehicles, technology infrastructure, partnerships, and resources necessary to smooth the care process.

One of the challenges will be finding the right balance between service line centered initiatives and hospitalwide priorities. Take hospital readmissions as an example. While many patient health status measures are necessarily viewed through the lens of a service line, Boutwell argues that readmissions should be measured hospitalwide.

"The limitation of disease-specific approaches to measuring readmissions or transitions of care is if someone's in for surgery and they're readmitted 10 days later with heart failure exacerbation, then the surgical service line would say that is unrelated readmission," she says.

Ultimately, there are limits to how effective leaders can be in the current system, which doesn't sufficiently reward care coordination. But savvy leaders know what the future looks like. Medicare is already denying payment for preventable errors and testing bundled payments with the ACE demonstration program. The healthcare reform debate has included talk of bundling payments and rewarding quality care. It may only be a matter of time until care coordination is tied directly to reimbursement.

The impetus is on hospital leaders now to figure out how to put the pieces together—whether to partner with or own postacute care facilities, how to engage physicians, and how to benchmark success—both for the patient's sake and for their own future success.

"We already see evidence and examples of hospitals who are partnering with nursing facilities, home health agencies, and saying, 'We're going to work on our part, you work on yours, together we'll reduce avoidable readmission rates by this type of a goal,'" says Boutwell. "They're basically laying the groundwork to be able to thrive in a new payment reform environment."

Elyas Bakhtiari

Possible Models

While hospitals are making progress in linking the care continuum at the ground level, policymakers are exploring reimbursement changes and new care models that would encourage greater collaboration and coordination between providers:

Bundled payments: Instead of being paid for procedures, under a bundled-payment system a stakeholder—most likely an acute care hospital—receives a lump sum of money for an entire care episode, including diagnosis, treatment, and postacute care. If all providers receive a single set of funds, they are more likely to work together to provide the best value, the logic goes.

Accountable care organizations: Like bundled payment systems, ACOs require collaboration between physicians and hospitals. However, providers still bill under fee-for-service. They are held jointly accountable—and become eligible for possible reimbursement incentives—for meeting and improving certain quality benchmarks.

Advanced medical homes: The advanced medical home is primarily built around primary care. The goal is to develop a patient-centered care model that emphasizes coordination and prevention.

Elyas Bakhtiari

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