A Health Services Research special issue outlines best practices that improve quality without raising costs—and possibly lowering them.
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| Carolyn M. Clancy, M.D. | Irene Fraser |
There is good news and bad news in the nation’s quest for quality health care. The good news is that the Agency for Healthcare Research and Quality’s (AHRQ’s) latest quality report shows that the rate of improvement in 41 core measures is up 2.3 percent over last year, a small number compared with where we need to go, but at least movement in the right direction. The bad news is that costs in the meantime grew by 6.7 percent.
We are not the first to notice this mismatch, of course. Employers and public payers such as Medicare and Medicaid have been concerned for years, and have been looking for strategies to either limit costs or shift them to others. Consumers clearly have been feeling the impact as well. We have a growing number of uninsured, and even those with coverage report delaying needed care because of out-of-pocket costs.
Hospital and health system leaders are also feeling the impact of rising costs and cost concerns. The high number of uninsured and underinsured people means uncompensated care, overcrowded emergency rooms and, often, sicker patients. Hospitals with a large number of government-insured and no-pay patients find it hard to remain solvent, and financial distress, in turn, makes it difficult to make needed investments in quality.
A Process Redesign
The search for a magic bullet to mitigate cost growth and the cost-quality mismatch has been ongoing for several years, with a focus on health information technology, payment incentives, consumer incentives and more. While these are all critical tools, there is growing recognition that the real payoff will come from changing the way we deliver health care—redesigning the process so it improves quality and limits cost growth.
Moving to a more efficient health care system is going to take a great deal of work and a strong evidence base. As first steps, AHRQ has published an evidence review of efficiency measures, and this year for the first time the agency included potential measures of efficiency in the National Healthcare Quality Report. But the most urgent need is for solid, practical, timely evidence on the process changes that improve efficiency.
This brings us back to more good news. A small but growing body of literature is showing that serious redesign efforts can simultaneously improve quality while maintaining or even reducing costs. AHRQ has brought the best of it together in “Improving Efficiency and Value in Health Care,” a theme issue of Health Services Research (HSR) released in October 2008. This issue—the journal’s first theme issue—brings together world-class work from seven research teams on what some hospitals and other providers are doing to improve efficiency.
Lessons for Hospital Leaders
The theme issue provides several lessons for hospital and system leaders:
Bite off what you can chew. One research team examined 21 common quality improvement programs (such as Six Sigma, 100,000 Lives Campaign and others) in over 100 Minnesota hospitals to try to answer the logical first question in quality improvement: “Where do we start?” The team found that hospitals vary in ability to pursue quality improvement, and quality improvement efforts in turn vary in difficulty. Determining your own capacity for sustained change is an important step in designing a successful quality improvement initiative. Success at one level can help support the next. But attempting an effort not matched to capacity can lead to higher inefficiency.
Listen to the front line. By leveraging the expertise of those on the front line, it is possible to identify efficiency problems that never would have been discovered under traditional methods. In one study, front-line workers reported that 36 percent of hospital work system failures fell into two categories: equipment/supply or facility.
Recognize that higher efficiency and better safety can coincide. Adverse patient outcomes account for about 3 percent of hospital inefficiency. Safety problems are costly, often requiring longer length of stay or readmissions. Investigators have also found that hospitals on average could increase admissions and patient visits by 27 percent by eliminating inefficiency.
Lessons for Policymakers
The issue also includes findings of interest to policymakers. For example:
Tiered networks can motivate patients. In a study tracking the impact of a tiered network in Minnesota, investigators found that financial incentives influenced patients’ choice of hospital for nonsurgical admissions, but not for surgery.
Specialty hospitals don’t necessarily improve efficiency. Researchers found that surgical and orthopedic specialty hospitals were significantly less efficient than traditional full-service hospitals, though cardiac specialty hospitals were more efficient.
Growing the Evidence and Spreading Success
To improve the value of health care, we will need a solid body of evidence on what strategies improve not only safety, quality and effectiveness, but efficiency as well—efficiency within organizations and efficiency across organizations in the marketplace. AHRQ has begun a new value portfolio, in which we are working with researchers, providers and others to reduce health care waste while at the same time maintaining or improving quality. Identifying evidence-based measures and data for tracking costs as well as quality is a key starting point, but real progress will require solid evidence and implementation of proven strategies for improving efficiency.
Through this theme issue and several other recent AHRQ studies, AHRQ hopes to provide the evidence base that hospital and system leaders can build on to improve the value of health care. Supporting further work by providers, researchers and others on efficiency and value is a strong priority for the agency. We welcome suggestions from hospital leaders on ways we can be most effective as we continue this effort.
Carolyn M. Clancy, M.D., is director of the Agency for Healthcare Research and Quality (AHRQ) in Rockville, Md. Irene Fraser, Ph.D., is director of the Center for Delivery, Organization, and Markets at AHRQ.
Readers of H&HN OnLine can access the theme issue of Health Services Research at www.hsr.org.
Hospitals & Health Networks welcomes your comment on this article. E-mail your comments to hhn@healthforum.com, fax them to H&HN Editor at (312) 422-4500, or mail them to Editor, Hospitals & Health Networks, Health Forum, One North Franklin, Chicago, IL 60606.
