Getting Everyone on the Same Page to Achieve Healthcare Value

Many people talk about value, but—even though many examples exist of achieving good healthcare value—the momentum is slowed because the efforts often seem scattershot.

However, an Institute of Medicine (IOM) roundtable made up of influential figures in various sectors of American healthcare has come up with suggestions on how to get everyone on the same page to achieve value.

The roundtable, chaired by then-Mayo President and CEO Denis Cortese, MD, met in late 2008 in a workshop in Washington, DC. Their observations and opinions are included in a new IOM book released last month called Value in Health Care: Accounting for Cost, Quality, Safety, Outcomes, and Innovation. Here are some of the common themes they addressed:

Perceptions. Value means different things to different stakeholders, so clarity of concepts is key. The roundtable participants noted that for patients, perceived value in healthcare is often described in terms of the quality of their relationship with their physicians. For patients, value improvement may mean helping them better meet personal goals or living lives that are as normal as possible.

Overall, more services or more expensive services are not necessarily needed since patients are more likely driven by sensitivity to the value of time and ensuring that out of pocket payments are targeted to their goals.

On the flip side, clinicians and providers saw value as diagnostic and treatment approaches that "increased confidence in the effectiveness of services offered." And employers viewed value improvement in terms of keeping workers and their families healthier and more productive at lower costs.

For health insurers, value improvement was described as emphasizing interventions that are "crisply defined" and supported by "a high level of evidence as to effectiveness and efficiency." Health product innovators spoke of value improvement as a product that is better for an individual patient, more profitable, and contributes to "product differentiation and innovation."

Gain. Improving value requires reliable information, sound decision principles, and appropriate incentives. With reliable information as the starting point, the roundtable underscored the importance of adequate investment in transparency and continuous improvement regarding "safety, efficacy, effectiveness, and comparative effectiveness of interventions."

Action to improve value, therefore, requires the fashioning and use of "sound decision principles tailored to the circumstances and adequate incentives to promote the desired outcome."

Urgency: The urgency to achieve greater value from healthcare is clear and compelling. Increasing healthcare costs consistently outpace inflation—the participants agreed—squeezing out employer coverage, adding to the uninsured, and doubling out of pocket payments without commensurate health improvements. They heard that perhaps one third to one half of health expenditures were unnecessary for targeted health outcomes.

Decisions: Sound decision principles are rooted in issues specific to the patient, the evidence, the social context, transparency, and learning. Decision rules often seem to many stakeholders to be "vague, inconsistent, and poorly tailored to the evidence." The roundtable participants contended that success in tailoring decisions to circumstances lies with an adequate evidence base, and with the reliability and availability of information on costs and outcomes.

Incentives. Incentives should direct attention and rewards to outcomes, quality, and cost. Roundtable participants said that the rewards and incentives prevalent in the American healthcare system were poorly aligned to effectiveness and efficiency. They discussed how the current system encouraged care that was procedure and specialty intensive—discouraging primary care and prevention.

Limits. Value may be inversely related to the level of system fragmentation. Participants suggested that moving to value driven healthcare will require "broad organizational, financial, and cultural changes" that are not likely to be attainable with the current level of fragmentation in healthcare decision making.

Communication. System level value improvement requires more seamless communication among participants. The roundtable participants noted the existence of "significant communication gaps" among individuals involved in the care delivery process.

For instance, patients and providers were determined not to communicate well with each other about diagnosis and treatment options or cost implications. This is in part, they said, because of "complex administrative and rapidly changing knowledge environments" where necessary information was not readily available to either party.

Communication—by either voice or electronic means—was often "virtually absent" among multiple providers and provider systems for a single patient. This increased the prospect of service gaps, duplications, confusion, and harm, according to the participants. Also, communication among the many groups involved in developing evidence—and the practitioners applying it—was often "unstructured and may be conflicting."