The Strategy for Value Transformation
The strategic agenda for moving to a high-value health care
delivery system has six components. They are interdependent and mutually
reinforcing; as we will see, progress will be easiest and fastest if they are
advanced together. (See the exhibit “The Value Agenda.”)
The current structure of health care delivery
has been sustained for decades because it has rested on its own set of mutually
reinforcing elements: organization by specialty with independent
private-practice physicians; measurement of “quality” defined as process
compliance; cost accounting driven not by costs but by charges; fee-for-service
payments by specialty with rampant cross-subsidies; delivery systems with
duplicative service lines and little integration; fragmentation of patient
populations such that most providers do not have critical masses of patients
with a given medical condition; siloed IT systems around medical specialties;
and others. This interlocking structure explains why the current system has
been so resistant to change, why incremental steps have had little impact (see
the sidebar “No Magic Bullets”), and why simultaneous progress on multiple
components of the strategic agenda is so beneficial.
The components of the strategic agenda are not theoretical or
radical. All are already being implemented to varying degrees in organizations
ranging from leading academic medical centers to community safety-net
hospitals. No organization, however, has yet put in place the full value agenda
across its entire practice. Every organization has room for improvement in
value for patients—and always will.
1: Organize into Integrated Practice Units (IPUs)
At the core of the value transformation is changing the way
clinicians are organized to deliver care. The first principle in structuring
any organization or business is to organize around the customer and the need.
In health care, that requires a shift from today’s siloed organization by
specialty department and discrete service to organizing around the patient’s
medical condition. We call such a structure an integrated practice unit. In an
IPU, a dedicated team made up of both clinical and nonclinical personnel
provides the full care cycle for the patient’s condition.
IPUs treat not only a disease but also the related conditions,
complications, and circumstances that commonly occur along with it—such as
kidney and eye disorders for patients with diabetes, or palliative care for
those with metastatic cancer. IPUs not only provide treatment but also assume
responsibility for engaging patients and their families in care—for instance,
by providing education and counseling, encouraging adherence to treatment and
prevention protocols, and supporting needed behavioral changes such as smoking
cessation or weight loss.
In an IPU, personnel work together regularly as a team toward a
common goal: maximizing the patient’s overall outcomes as efficiently as
possible.
They are expert in the condition, know and trust one another, and
coordinate easily to minimize wasted time and resources. They meet frequently,
formally and informally, and review data on their own performance. Armed with
those data, they work to improve care—by establishing new protocols and
devising better or more efficient ways to engage patients, including group
visits and virtual interactions. Ideally, IPU members are co-located, to
facilitate communication, collaboration, and efficiency for patients, but they
work as a team even if they’re based at different locations. (See the sidebar
“What Is an Integrated Practice Unit?”)
Take, for example, care for patients with low
back pain—one of the most common and expensive causes of disability. In the
prevailing approach, patients receive portions of their care from a variety of
types of clinicians, usually in several different locations, who function more
like a spontaneously assembled “pickup team” than an integrated unit. One
patient might begin care with a primary care physician, while others might
start with an orthopedist, a neurologist, or a rheumatologist. What happens
next is unpredictable. Patients might be referred to yet another physician or
to a physical therapist. They might undergo radiology testing (this could
happen at any point—even before seeing a physician). Each encounter is separate
from the others, and no one coordinates the care. Duplication of effort,
delays, and inefficiency is almost inevitable. Since no one measures patient
outcomes, how long the process takes, or how much the care costs, the value of
care never improves.
Contrast that with the approach taken by the
IPU at Virginia Mason Medical Center, in Seattle. Patients with low back pain
call one central phone number (206-41-SPINE), and most can be seen the same
day. The “spine team” pairs a physical therapist with a physician who is
board-certified in physical medicine and rehabilitation, and patients usually
see both on their first visit. Those with serious causes of back pain (such as
a malignancy or an infection) are quickly identified and enter a process
designed to address the specific diagnosis. Other patients will require surgery
and will enter a process for that. For most patients, however, physical therapy
is the most effective next intervention, and their treatment often begins the
same day.
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