Lawrence Casalino M.D., Ph.D. Weill Cornell Medical College Sterling, VA February 16, 2011

1. IDENTIFYING KEY AREAS FOR DELIVERY SYSTEM RESEARCHThe Challenge and Promise of Delivery System Research: A Meeting of AHRQ Grantees, Experts and Stakeholders Lawrence Casalino M.D., Ph.D. Weill Cornell Medical College Sterling, VA February 16, 2011

2. This talk - a quick overview: • what is delivery system research? • conceptual model • criteria for selecting key areas for delivery system research • four key areas and research questions • ARRA grantees 2

3. Why study the delivery system? • patients, legislators, the media, physicians mostly don’t see a problem But: • the discoveries of basic scientific and clinical research do not help patients unless they are effectively used in the delivery system. 3

4. What is delivery system research? • focuses on organizations that provide health care and/or • inter-relationships among these organizations 4

5. Generic model of an organization and its incentives 5

6. Criteria for selecting key areas for delivery system research (1) • will this research help patients—either directly or by helping providers to provide better care? (Clancy) • does this research have potential for a major impact on the population as a whole or on subgroups? (IOM) 6

7. Criteria for selecting key areas for delivery system research (2) • focuses on areas emphasized by the health reform law • studies both intended and unintended consequences 7

8. Criteria for selecting key areas for delivery system research (3) • Objective: to get providers into high performing organizations and give these organizations incentives to continually improve care for their population of patients - therefore: • identify types of organizations that tend to be high performing • identify incentives likely to lead to creation of these organizations and to movement of providers into them • identify incentives for organizations to improve care 8

9. Major gap in research and funding: • focus mainly on processes of care, particularly intraorganizational processes • this is important, but difficult to generalize, because: • process effectiveness depends on the way it is implemented and on the context within which it is implemented • most attempts to improve care involve multiple processes; how do we know which are important? • also, organizations unlikely to adopt a process unless they have adequate incentives to do so 9

10. Qualifications/limitations • just my opinions - no compelling evidence • somewhat arbitrary choices - even with agreement on criteria, many choices are possible • see the “long list” and the rest of the “short list” • see the reasons given for selecting these areas • better to be provocative and wrong than to be too general • key areas likely to change over time 10

11. Key research area #1 • analyses of the demographics of the delivery system—i.e., of each component of the conceptual model • and of relationships among the components of the model 11

12. Why? • knowing the demographics is an essential first step, which would make it possible to study in a generalizable way the inter-relationships outlined in the conceptual model between structure, incentives, processes, and outcomes • huge gaps in knowledge • very little funding available for this 12

13. Examples of research questions • which type of medical group performs better: • small, medium, large? • single specialty or multispecialty? • hospital or MD-owned? • is the percentage of physicians employed by hospitals increasing? If so: • why? • is this a good thing? 13

14. Key research area #2 • analyses of ways to structure incentives so that they lead to: • desirable changes in the demography of organizations in the delivery system • continual efforts by these organizations to improve the health of their populations of patients 14

15. Why? • incentives likely to be critical • despite funding, we are far from having definitive answers 15

16. Examples of research questions • compare the effects of different payment methods on quality, costs, and the demography of the delivery system • how can undesirable unintended consequences of external incentive programs be minimized? 16

17. Key research area #3 • how can performance measurement be improved? 17

18. Why? • hard to improve what you can’t measure • we often measure less, rather than more, important things • increased reliance on external incentives (e.g. P4P, public reporting, “shared savings”)  measures had better be good 18

19. Examples of research questions • at what level is it desirable and feasible to measure quality (e.g. individual MD, medical group, accountable care organization)? • how much weight should be given to patient experience in evaluating quality? • how can electronic medical records be used to measure performance? 19

20. Critical research area #4: • Analyses of interprovider/interorganizational processes for improving care 20

21. Why? • may be a major source of poor quality/poor patient experience/high costs • little is known about this area 21

22. Examples of research questions • can small practices effectively share resources (e.g. nurse care managers)? • how valuable is phone communication among physicians about patients (even when patient is not referred)? If valuable, how can it be encouraged? 22

23. AHRQ ARRA CER Grantees • lack time to do this any sort of justice • 4/6 evaluation grants and 4/4 demonstration grants can be categorized as falling into the key areas suggested here 23