It is an exciting time indeed! Presidential debates, political agendas in play, international and domestic issues front and center, major decisions that will impact the lives of all Americans…and none more important than health care reform!
I’d like to call your attention to a recent Op-Ed in the Milbank Quarterly titled Health Services Research, Medicare, and Medicaid: A Deep Bow and a Rechartered Agenda, authored by Donald M. Berwick, former administrator of the Centers for Medicare and Medicaid Services (CMS).Under his leadership, CMS set and promoted policies, regulations, and daily operations that set a new course in health reform with the goal of achieving the “Triple Aim.” He acknowledges progress made but admits to remaining gaps where health services research (HRS) has played an important role to date, and undoubtedly will play a crucial role in the future, to recharter an agenda to improve health care for all Americans.
Dr. Berwick proposes ten suggested topics for HRS to focus on in the next decade. I have taken what I consider the top five of these to bring to your attention. I have adapted the focus of these topics as they are relevant to any health care provider organization.
- Better ways to involve health care providers in change. There is a national movement to engage health care providers in the pursuit of quality improvement and lower costs. The current strategies involve changing payment, incentives, or what is referred to as “carrots and sticks.” I believe these can be effective tools to implement change, but certainly not the only tool in our toolbox. Dr. Berwick challenges us to think about different approaches to training, support, organizational design, information technology, and leadership practices — as well as payment — designed to improve health care.
- Transitional business models for providers. Fee-for-service (FFS) payment is unsustainable. Yet many hospitals and clinics remain tethered to business strategies that depend on FFS. Dr. Berwick describes the image of a health care executive with “one foot on the dock and one foot on the boat,” torn between volume-driven payment and global payment in some form. He argues that we must continue to rigorously test and evaluate payment models for the transition to new payment approaches. Once this is done, you can then move toward scaling (one of the other ten recommendations).
- Understanding the nature and magnitude of waste in health care. There is much literature on unnecessary use of practices and procedures. We do know this: waste is pervasive in health care and that costs vary greatly without correlation with quality or outcomes. Are we getting the best outcomes for our current health care investments? Not really. Are there are other ways being tested around the country that are informing us about more effective and efficient ways of delivering care at lower cost? You bet! Stay tuned for more on that!
- Creating the new workforce. Innovative and new health care designs and operations may require new clinical roles (or reframing of roles) and workflows that change the professional identity and boundaries of the guild associations. These professional associations have historically staunchly defended their guilds. However, the good news is that is changing! Data and evidence, related to effective training and clinical approaches, workflows, costs and health outcome data will help drive and shape the health care workforce of the future, which includes telehealth (another of the ten recommendations).
- Rationalizing measurement. Performance measurement varies considerably with agencies, policy makers and payers, setting mandates for metrics in the form they want them, when they want them, and from whom they want them. Metrics should be evaluated closely if they are the “correct” metrics to collect, how these metrics are being used to assess population based health outcomes and performance and “right sizing” the metric dashboard. Costs and benefits of metrics must understood and agreed upon, in order to have true buy-in from health care providers on which metrics add value in their use and which do not. This is also related to Developing more dynamic evaluation methods (another of the ten recommendations) or program evaluation methods.
Dr. Berwick acknowledges the progress made by instituting Medicare and Medicaid policies, regulations, and operations with the aim of the Triple Aim. During a time of tremendous conflict and confusion in health care policy, collectively, we have the opportunity to lead health care reform on new paths to better care, improved population health, and lower costs.