I recently attended a course at the Harvard Business School called Strategy for Health Care Delivery , which is based on this text. The main thrust of the course and book is that health care delivery will improve only if we focus on what has value for the patient and design the system accordingly. Such a system would have six components:
- Organize into integrated practice units that provide care for patients with a specific condition, rather than around provider specialties. A simple way to think about this is that we would organize around demand rather than supply.
- Measure outcomes and costs for every patient. Outcomes can be grouped into three tiers: health status (e.g., survival); process of recovery (e.g., time to return to work); and sustainability of health (e.g., function at some time after treatment). Recommended approach to cost is time-driven activity-based costing, which involves tabulating how much time each type of staff person spends with the patient and how much each staff person costs. Paraphrasing one of the course instructors: health care delivery has tended to be a fact free zone and people in fact free zones happily assume they are doing well.
- Move to bundled payments for care cycles. Secretary Burwell has instructed CMS to do exactly this with Medicare payments! The trick is to figure out what the appropriate care process is and price it accordingly.
- Integrate care delivery across separate facilities. The notion here is that high volume facilities and providers are likely to provide higher quality care than low volume facilities and providers, which in turn means having facilities specialize rather than try to offer a full suite of services.
- Expand excellent services across geography. This is closely related to item 4. Patients may have to travel to get care, particularly for rarer conditions.
- Build an enabling information technology platform. The other five items all require that this platform exist and function. Quoting a colleague in the course: Epic is not the end of EHR development.
The course included discussion of 5 cases: head & neck cancer at MD Anderson Cancer Center; knee and hip replacement at Hoag Orthopedic Institute; congenital heart defect care at Texas Children’s Hospital; bundled payment for knee and hip replacements in the County of Stockholm (Sweden); and the Cleveland Clinic. There are fantastic activities going on at all these institutions that build on the aforementioned six components. My observation is that the efforts are all driven by a passionate and talented senior leader; four of the five were created in response to a triggering event of some sort. I left the course excited about these ideas and looking forward to figuring out how NCI can invest in research to generate evidence to inform delivery system redesign.