HLM: What other kinds of measurement do you see in the future?
DB: Measures of patient voice, through the patient's eyes. We're getting more careful and thorough about asking patients about their experiences, and having that be the goal, and making sure that transparency, above all, is the rule. Transparency almost always helps.
HLM: I've heard talk about functional outcomes.
DB: Those are very important, obviously. For example, for patients with stroke, to what level of function do they return?
HLM: What I've been hearing is that there's a disconnect between value as a goal and a fee-for service world. How fast do you think that will tilt to one based on performance?
DB: I don't know. But you can improve in a fee-for service world. That's been done for decades, but it's better if you have a system in which payment is comprehensive and global, so people can put resources where they need to be. So you can send nurses to someone's home if you want instead of building a new (cardiac) cath suite.
Fee for service is a serious problem. It drives volume, it drives overuse. No payment scheme is perfect, but fee for service seems to have particular toxicity. Yet as I go around the country, some communities are really ready now to take a major step away from fee-for-service, almost completely. Others are clinging to it because they think there's something very good about what it does for the freedom of caregivers.
I think there's going to be a lot of variation around the country, with Massachusetts getting away from fee-for-service, Maryland trying to build on its tradition of the all-payer system, and Arkansas is moving toward bundled payments.
End of Part 1.