PatientsChartingCourse

Perverse economic and practice incentives. The fee-for-service reimbursement system rewards service volume rather than value.

System fragmentation. Multiple, disconnected, and uncoordinated decision points in healthcare delivery and finance are fundamental challenges to efficient­ and effective care.

Opacity as to cost, quality, and outcomes. Without meaningful and trustworthy sources of information on costs and outcomes of care, neither patients nor their clinicians can make fully informed decisions.

Changes in health status. An aging population, the growing prevalence of obesity, and increases in multiple co-occurring, complex chronic diseases are accelerating the need for health services.

Lack of patient involvement. The culture of care is not yet conducive to active patient participation in care decisions, despite growing use of webaccessible information and evidence of the positive effect of shared decision making on health outcomes.

Under-investment in population health. Because health status is importantly influenced by behavioral, social, and environmental factors, progress depends on a stronger commitment to population-wide health programs.

Corrective levers

Streamlined and harmonized health insurance regulation. Reduce complexities and inconsistencies in coverage standards and requirements often unique to a jurisdiction.

Administrative simplification and consistency. Streamline and harmonize inconsistent payment and reporting requirements that create unnecessary and excessive administrative costs.

Focus incentives on results and value. Focus payments on outcomes and value, and increase targeting those at highest risk of poor outcomes.

Quality and consistency in treatment. Establish treatment guidelines as the starting point for effective care, tailoring as indicated, and capturing the care experience for continuous improvement.

Evidence that is timely, independent, and understandable. Foster effective care through a dedicated, unified program that provides reliable guidance;

keeps up with innovation and changing science; and improves practice reliability, consistency, and impact.

Clinical records that are reliable, sharable, and secure. Use electronic health records to enhance the effectiveness and efficiency of care, facilitate patient handoffs, provide clinical decision guidance, and foster patient involvement.

Data that are protected but accessible for continuous learning. Create a digital utility with clinical data as a resource for real-time monitoring of the results of treatment, ongoing generation of new evidence for effective care, and continuous care improvement.

Transparency requirements on cost, quality, and outcomes. Build an accessible information resource, with transparency as to cost, outcomes, and value serving as a critical element of system change.

Culture and activities framed by patient perspective. Position patient perspectives and needs as primary—and convenience and interest as secondary­—for the design and execution of healthcare organization and delivery.

Medical liability reform. Diminish defensive medicine as a detrimental, significant driver of unnecessary services and procedures—e.g., through harbors for best evidence practices, caps on non-economic damages, specialized tribunals.

Prevention. Elevate the focus on prevention, ranging from clinical preventive services to community health and wellness.

10. VALUE

Value in Health Care: Accounting for Cost, Quality, Safety, Outcomes, and Innovation

Urgency: Increasing healthcare costs consistently outpace inflation, squeezing out employer coverage, adding to the uninsured, and doubling out- of-pocket payments—without commensurate health improvements. The long-term consequences for federal budget obligations, driven by the growth in Medicare costs, amount to an estimated $34 trillion in unfunded obligations.

Perceptions: We have heard that for patients perceived value in health care is often described in terms of the quality of their relationship with their physicians. Clinicians discussed value as diagnostic and treatment ap-

proaches that offer increased confidence in the effectiveness of services offered. Employers viewed value improvement in terms of keeping workers and their families ­healthier and more productive at lower costs. For health insurers, we heard that value improvement means emphasizing interventions that are crisply defined and supported by a high level of evidence. Health product innovators spoke of value improvement as a product that is better for the individual patient, more profitable, and contributes to product differentiation and innovation.

Elements: Value from health care has dimensions beyond the nature, cost, and effectiveness of a particular intervention, including those related to elements such

as preference, satisfaction, and appropriateness to circumstance. Value determination also means determining the right price, and we heard that, from the demand side, the right price is a function of perspective. From the supply side, the right price is a function of the cost of production, the cost of delivery, and the incentive to innovation.

Gain: Because reliable information is the starting point for improving value, discussants underscored the importance of adequate transparency and continuous improvement of insights on the safety, efficacy, effectiveness, and comparative effectiveness of interventions.

Decisions: Currently, decision rules seem to many stakeholders to be vague, inconsistent, and poorly tailored to the evidence.

Information: Because the quality of evidence varies, as do the methods used to evaluate it, transparency as to source and process, care as to interpretation, and clarity in communication were noted as key.

Incentives: Often noted in the workshop discussions was that the incentives prevalent in the American healthcare system are poorly aligned to effectiveness and efficiency, encouraging care that is procedureand specialtyintensive and discouraging primary care and prevention.

Limits: We have heard that obtaining the value needed will continue to be elusive until better means are available to draw broadly on information as to services’ efficiency and effectiveness, to set priorities and streamline

approaches to filling the evidence gaps, to ensure consistency in the ways evidence is interpreted and applied, and to marshal incentives to improve the delivery of high-value services while discouraging those of limited value.

Communication: Patients and providers do not communicate well with each other about diagnosis and treatment options or cost implications. Communication is often absent between multiple providers for a single patient,­ increasing the prospect of service gaps, duplications, confusion, and harm, according to discussants. Further, communication between scientific and professional organizations producing and evaluating evidence is often limited, resulting in inefficiencies, missed opportunities, and contradictions in the production of guidance.

Providers: We heard that the clearest barriers to provider-level value improvement appear to lie in the lack of economic incentives for a focus on outcomes and also in cultural and structural disincentives to tend to the critical interfaces of the care process—the quality of the links in the chain of care elements.

Patients: It was noted that patients most often think of value in terms of their relationship with their provider but ultimately the practical results of that relationship, in terms of costs and outcomes, hinge on the success of programs that improve practical, ongoing, and seamless access to information on best practices and costs and of payment structures that reward accordingly. Workshop discussants offered insights into the use of various financial approaches to sensitize and orient patient decisions on healthcare prices according to the evidence of the value delivered.

Manufacturers: Health product manufacturers and innovators naturally focus on their profitability but because product demand is also derived from the ability to demonstrate advantage with respect to outcomes and efficiency, manufacturers expressed an interest in regulatory and payment approaches that enhance performance on outcomes resulting from product use.

Tools: Despite the broad agreement on their importance, we heard that the analytical tools and capacity to evaluate, in either absolute or comparative terms, the basic elements of value—outcomes and costs—are substantially underdeveloped and will need greater attention.

Opportunities: Although attaining better value in health care depends on reducing the fragmentation that is its central barrier, we heard a number of examples of measures that might be taken at different levels, both to achieve better value now and to set the stage for future progress.

11. LEADERSHIP

Leadership Commitments to Improve Value in Health Care: Finding Common Ground

Build trust and collaboration: Health care depends for its effectiveness on the close cooperation of all parties involved. Building trust and facilitating transformative change will require broader-based collaboration and cooperative stakeholder engagement.

Foster agreement on “value” in health care:

Although all participants agreed on the centrality and importance of the value achieved from health care, different groups often think of value in different ways. A multistakeholder effort might drive clarity and consensus on those principles and elements of value common to all stakeholders.

Improve public understanding of evidence: Too often, people perceive that certain common terms such as “evidence based,” “research,” “medical necessity,” and “risk” suggest a restrictive or experimental element to their care. It will take systematic and coordinated communication strategy to better convey the central concepts that medical evidence is dynamic, that evidence-based medicine is the provision of care that the evidence suggests is best for any given patient at any given point in time, and that health care is a joint patient–provider endeavor.

Characterize the impact of shortfalls in the evidence: Documenting the consequences of provision of care on the basis of too little evidence or the potential benefits of providing care on the basis of the right evidence is a prerequisite to obtaining an improved understanding of and demand for evidence-based care and stakeholder activation.

Identify the priorities for evidence development: The first step to a systematic and coordinated effort to conduct the most important assessments is the identification of the priorities as a sort of consensus national problem list and research agenda of the most pressing issues for medical care decisions.

Improve the level, quality, and efficiency of the research: Policies that facilitate the ability to use clinical data to monitor the effectiveness of in-

terventions are needed. Novel approaches to the conduct of clinical trials are needed. A more structured lexicon for “best practices” in undertaking observational studies may be necessary.

Clarify and promote transparency: Consensus is needed to establish common principles of transparency and standards for how they should be applied­ in each sector. One starting point might be with principles for evidence interpretation.

Establish principles for the interpretation and use of evidence: Decisions on market approval, insurance coverage, provider use, and patient acceptance are all informed by some interpretation of the evidence. Clarity of the guiding principles is important.

Improve engagement in the full lifecycle of interventions: Many factors are at play for each intervention—for example, similarity to previously tested interventions, the safety and effectiveness of an intervention for some populations but not others, the availability of biomarkers predictive of efficacy, and costs that vary by scale and stage of application or by the need for later services. Facilitating innovation, access, and effective information gathering while emphasizing patient safety, appropriate application, improved outcomes, and efficiency will require a set of lifecycle-oriented decision-making rules that are more carefully considered than they are at present.

Focus on frontline providers: Accelerating the translation of clinical research into practice involves addressing matters of professional education, credentialing, licensure, practice support, economic incentives, patient acceptance, and the culture of care. It will require the central and coordinated involvement of the organizations that represent those providers.

Foster a trusted intermediary for evidence: In this information age, healthrelated information is constantly presented through news reports, marketing, professional organizations, journals, and the Internet, but it is often confusing and even contradictory. A trusted information source—one that is independent but that engages all stakeholders—is needed to identify gaps; set priorities; establish standards; and guide the development, interpretation, and dissemination of evidence on clinical effectiveness.

Build the capacity to meet the demand: Currently, the combined resources of the various public and private organizations involved in studying comparative clinical effectiveness meet but a small and scattered fraction of the demand. The centrality of the problem to the quality and efficiency—

the viability, according to some—of the nation’s healthcare system may require the creation of a new independent entity devoted to the work.

Create incentives for change: Economic and policy incentives to engage the use of the best available evidence and more fully engage patients in the clinical decision-making process include the alignment of purchasing incentives accordingly when value is determined; use of the reimbursement power of insurers and other financial incentives to generate new insights from medical care (e.g., coverage with evidence development); and the linkage of purchaser and payer decisions to performance incentives for best practices, outcomes, and the better secondary use of routinely collected data.

Accelerate advances in health information technology: Health information technology can facilitate the development of learning networks and accelerate the generation of evidence, enable data aggregation and utilization, deliver evidence to the point of care, and expand research capacities. Coordinated stakeholder action—and financial incentives—should be able to speed the progress toward universal application of electronic health records and access to information both on basic interoperability issues (e.g., standards and vocabulary) and, possibly, the development of more radical data search innovations.

OTHER PUBLICATIONS IN THE

LEARNING HEALTH SYSTEM SERIES

The Learning Healthcare System

Evidence-Based Medicine and the Changing Nature of Health Care

Leadership Commitments to Improve Value in Health Care: Finding Common Ground

Value in Health Care: Accounting for Cost, Quality, Safety, Outcomes, and Innovation

Redesigning the Clinical Effectiveness Research Paradigm:

Innovation and Practice-Based Approaches

Clinical Data as the Basic Staple of Health Learning: Creating and Protecting a Public Good

The Healthcare Imperative: Lowering Costs and Improving

Outcomes

Learning What Works: Infrastructure Required for Comparative Effectiveness Research

Engineering a Learning Healthcare System: A Look at the Future

Digital Infrastructure for the Learning Health System: The Foundation for Continuous Improvement in Health and Health Care