New Delivery Models: Implications for Performance Measurement

1. 38th American Academy of Nursing Meeting & Conference Performance Measurement: Strategic Imperatives for Nursing New Delivery Models: Implications for Performance Measurement Laura L. Adams President & CEO, Rhode Island Quality Institute, Providence, RI Faculty, Institute for Healthcare Improvement, Boston, MA Immediate Past Board Chair, National eHealth Collaborative, Washington, DC October 13, 2011

2. Some Key Drivers of U.S. Healthcare’s Cost and Quality Problems • How it’s financed (what’s paid for, by whom and at what price) • How it’s delivered There’s a urgent need to redesign BOTH…

3. The Prevalent (and Toxic) Financing System • Payment to providers is on a “piecework” basis—the more pieces produced, the greater their reimbursement. Quality isn’t often figured into the payment—the worst cardiac surgeon, primary care doctor, etc., gets paid the same as the best. • Market forces (e.g. competition) don’t work in healthcare – the more MRI machines, the more MRI’s; the more doctors per capita, the more tests and procedures per capita, regardless of need (Wennberg, et.al.). • Providers are often harmed financially if they improve quality, safety and efficiency. • Little incentive to produce efficient, effective care—in fact— a financial disincentive to produce it.

4. Then there’s the delivery system…

5. The current system fragments patient information resulting in errors and inefficiency Hospitals, LTCs, BH /SA Facilities, etc. Dept. of Health Public Health Laboratories Primary Care (incl. Behavioral Health/Substance Abuse, CHCs, Free Clinics, etc.) Pharmacies Patients and Families Specialty Physicians Payers Ambulatory Centers (e.g. imaging centers) Adapted from: Indiana Health Information Exchange

6. Summary of Today’s Healthcare: A Familiar Story • A complex, fragmented, & confusing system • Very little coordination • Very little or no incentive to limit care • Inadequate data to assess cost-effectiveness , cost growth or utilization trends • Variations in care with no apparent benefits • Despite our best intentions, harming patients and families every hour of every day

8. Some Implications of New Payment Systems • The majority of the savings come from hospitals; Essentially, hospital are creating new business models • Reduction of potentially-avoidable admissions, re-admissions & ED visits • Reduction of duplicate diagnostic tests • Greater efficiencies/fewer complications during stays • Hospitals must integrate (virtually and otherwise) with their communities like never before • Community-based providers • Quality improvement collaboratives • Community-wide health IT initiatives • Community-wide metrics to track performance

9. New Competencies and New Opportunities • Payment Reform: Physicians, hospitals, long-term care providers, etc. will be paid to produce quality—not financially harmed for doing so • Quality Improvement/Delivery Redesign: Now a key business strategy for physicians, hospitals, long-term care facilities and other health care providers • Health Information Technology: The necessary foundation for improving quality and succeeding financially

10. Hard to track and improve key metrics such as preventable hospitalizations and ED visits Hospitals, LTCs, BH /SA Facilities, etc. Dept. of Health Public Health Laboratories Primary Care (incl. Behavioral Health/Substance Abuse, CHCs, Free Clinics, etc.) Pharmacies Patients and Families Specialty Physicians Payers Ambulatory Centers (e.g. imaging centers) Adapted from: Indiana Health Information Exchange

11. HIEs Represent New Opportunities for Performance Measurement Hospitals, LTCs, BH /SA Facilities, etc. Dept. of Health Public Health Primary Care (incl. Behavioral Health/Substance Abuse, CHCs, Free Clinics, etc.) Laboratories Health Information Exchange Pharmacies Patients and Families Specialty Physicians Payers Ambulatory Centers (e.g. imaging centers) Adapted from: Indiana Health Information Exchange

12. Potential Unintended Consequence of ACOs, Bundled Payments, etc.? Hospitals, LTCs, BH /SA Facilities, etc. Dept. of Health Public Health Primary Care (Incl. Behavioral Health/Substance Abuse, CHCs, Free Clinics, etc.) Laboratories Community- wide HIE Pharmacies Patients and Families Specialty Physicians Payers Ambulatory Centers (e.g. imaging centers) Adapted from: Indiana Health Information Exchange

13. A Sampling of What Patients & Families Are Telling Us About the Role of Health IT • We want to be full-fledged members of the care team: “Nothing about me without me”. • We don’t want to be lost in the healthcare system or have to “navigate” it. • We do more to manage our care than you do. Please keep that in mind in designing new IT-enabled systems. We need access to our own information just as badly as you do—probably more so. We consider the data we supply as just as important as the data that the healthcare system supplies. • We want our information to follow us—anytime and anywhere. • We want control over access to our information--this means that you don’t freely distribute it or block its flow without our consent.

14. Implications for Performance Measurement • Measurement will have to be designed to reflect the performance of the health care system across communities and across proprietary boundaries – not just within individual health systems/ACOs • There will be great opportunities for performance measurement created by some community or state-wide health information exchanges (HIEs) • Data across proprietary boundaries • Comprehensive, longitudinal databases • Patient/consumer reported metrics are becoming critically important as new models of health and wellness are created

15. Contact Information Laura Adams, President & CEO Rhode Island Quality Institute 235 Promenade Street, Suite 600 Providence, Rhode Island, 02908 ladams@riqi.org 401-276-9141 extension 271