Welcome to Value-Based Care, Value-Based Quality and Safety. This is Lecture a. The objectives for this lecture, overview of value-based quality and safety are to define quality, patient safety and value of care. Identify current gaps in health quality. Discuss how healthcare quality is a foundation for value based care. Discuss the financial imperative of value based care. Describe the reasons for the shift to value based care models. Quality in healthcare has many definitions, and refers to many things. It can be quality metrics that are industry specific, it can refer to care at the bedside, or it can be how various processes are used in an organization to deliver care services. We will use two very well known and common definitions of quality. The first is one proposed by the Institute of Medicine, or IOM. The second was developed by the Agency for Healthcare Research and Quality, or AHRQ. The IOM defines quality as care that is safe, effective, patient-centered, timely, efficient, and equitable. AHRQ defines quality as doing the right thing for the right patient at the right time in the right way to achieve the best possible results. Both definitions cover the overarching spectrum of quality in healthcare, providing optimal care to all patients that achieves the expected outcomes. These definitions encompass quality as a multi-faceted outcome that occurs across the healthcare continuum, and where provision of care services is key. Quality can be measured at the individual, organization, and population level. The Institute of Medicine's report in 1999, to err is human, lead to a dramatically increased emphasis on patient safety and healthcare. This report startled the healthcare industry by showing that approximately 44,000 to 98,000 Americans die every year as a result of preventable patient safety lapses while receiving care in a healthcare organization. This makes patient medical errors the eighth leading cause of death in the United States. For this lecture, we will adopt the Institute of Medicine's definition of patient safety as freedom from accidental injury. Error is the termed used to denote a non-purposeful action or event that results in a negative or unexpected outcome. Understanding the definition of error is important, and in this unit, we adopt the following definition of error from the IOM report. The failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim. Note that error can be either, an error of execution when actions do not proceed as expected or an error of planning, when the initial plan of action is not the correct one. Value of care is a fairly new term in the healthcare industry and reflects the effort of our industry to find mechanism to quantify quality care. Quantifying means determining how much it costs to achieve the desired and expected quality outcomes. For this unit, we adopt the National Quality Form's definition of value as, a measure of a specified stakeholder's preference-weighted assessment of a particular combination of quality and cost of care performance. In other words value can be defined as how much you are required to pay to achieve, or attain specific out comes. Notice, the outcomes can cover a board range of areas important in healthcare. Health out comes, safety events, and excellence in care service. Value and value based care is becoming one of the most emphasized goals in healthcare. In the US, there are puzzling results related to the proceed of quality. The United States spends approximately $2 trillion a year on healthcare. Approximately 16% of the gross national product or $8,508 per person per year, the highest in the world. Yet among the leading nations of the world, Britain and Canada for example, health outcomes are poor in our country. For example, the overall score for healthcare outcomes in the United States is eleventh out of eleven nations. We're also the worst nation for health equity, efficiency, and healthy lives. These data provide evidence that we have gaps in the quality of care being provided. These gaps include underuse, many people do not receive medically necessary care. For example, regular screening exams such as mammography and prostate screening, are not utilized. Misuse, when patients are harmed or receive the wrong care. For example, patients receive the wrong medication or contract hospital acquired infections. Overuse, many patients receive care that is not needed or for which there is an equally effective alternative that costs less money or causes fewer side effects. For example, utilization of diagnostic tests that often don't contribute to making a diagnosis. Sometimes this is referred to as defensive medicine. These are some examples of some of the under-use, misuse and overuse in our healthcare system that contributes to poor quality outcomes for patients and their families. According to the NCQA, evidence-based care was given only 55% of the time. And that 91,000 Americans died each year because they didn't receive the appropriate evidence-based care. Over 100,000 patients were injured as a result of receiving inappropriate or wrong care. With these and other such statistics, it is clear healthcare quality outcomes in our industry are not as good as they should be, and need substantive improvements. The release of Institute of Medicine's, To Err is Human report in 1999, launched a robust patient safety movement in our country. The report identified numerous patient safety outcomes that were poor. In addition to the avoidable deaths the cost of the safety events to our economy is as much as $29 billion per year. Many newer reports including a white paper from the National Patient Safety Foundation, report that annual deaths as a result of safety errors is far higher than was found by the IOM. In fact, they estimated that 440,000 people a year die from medical error which would make it the third leading cause of death in the United States. However, the IOM report notes that the majority of these safety error problems are systemic, not the fault of the individual providers. This means process and system improvements can be enacted by organizations to improve safety outcomes. With these very public and well known poor outcomes for patients and their families, coupled with the highest per capita spending on healthcare in the world, it makes sense that Americans are demanding better and more accountable healthcare in our country. Virtually all Americans want to know the quality of care they might receive from doctors and hospitals. 89% feel it is important that they have cost information before they actually get care. And 85% want to see payers reward high quality doctors and hospitals. Clearly, quality, safety and value have become priorities for American healthcare consumers. It is against this background of gaps in quality coupled with consumer demand for higher quality and more transparency, that the movement to value based care has developed. The response by the healthcare industry to unplanned safety errors and poor quality outcomes has been to advocate what is referred to as, the Triple Aim. Improving outcomes while reducing errors requires simultaneous pursuit of the three aims, which are improving the patient's experience of care, improving the health of populations, and reducing per capita costs of healthcare. Value-based healthcare cannot be achieved unless industry improvements pursue a system of these linked goals, that is, the Triple Aim. Measuring success of the efforts to achieve the triple aim requires quantifiable data on various care components. There is a need to establish a system of metrics and measurements that serve to assess progress in achieving the various aims. Some of the needed data include health outcomes important to populations. This would include such things as measures of health status or health related quality of life as well as health outcomes such as mortality. Data on costs of care and resource use, such a metric might be the total cost per patient per procedure. And finally, we need measures of patients' perception of their care experience. Care experience surveys such as HCAHPS have been used to obtain these measures. Achieving a system of quantifiable data requires four key factors. One needs to define the specific population of interest. It is also necessary to define metrics for outcome and process measures and for population and quality improvement project measures. One has to have the ability to gather data over a long time period. And finally, one needs to access benchmark or comparison data. The how to of a value-based care system with better quality outcomes related to cost and patient experience is captured very nicely in a model of value-based care described by Porter and Lee. First, a health care facility can organized into practice units which can help define the population of focus. Next, the organization need to establish relevant outcome measures and measure the outcomes as well as the cost. One way to lower costs is the increase the use of bundle payments, which reimburse providers for a suite of services associated with an episode of care. Integrating care across care facilities can improve continuity of care and also reduce errors. Once these processes are working well on a small scale, they can be expanded throughout a healthcare system. In order to achieve these aims, it is clear that a relevant and encompassing IT platform that supports integration, information gathering, data analytics, and reporting, is required. With all of the public demands for transparency and accountability, coupled with the industry's drive to improve the quality of care being provided and the outcomes experienced by the patient, the federal government has added a critical factor, financial incentives. This quote by Dr. Donald Burwick emphasizes the key need for financial incentives to be attached to quality outcomes. A major overarching theme in the Affordable Care Act is one of measurement, transparency, and altering payment to reinforce not simply volume of services, but the quality of the effects of those services. Instead of payment that asks, how much did you do? The affordable care act clearly moves us toward payment that asks, how well did you do? And more important, how well did the patient do? These two points are the heart of the growing drive for value based payment. The Centers for Medicare and Medicaid Services or CMS is the first and the largest healthcare pair to link outcomes to payment. CMS value-based programs serve to reward healthcare providers with incentive payments for the quality of care they give to people with Medicare. These programs add to CMS's larger quality strategy to reform how healthcare is delivered and paid for. CMS has aligned their value based programs with the goals of the Triple Aim. Currently, there are four programs. Hospital Readmissions Reduction Program, which reduces payments to hospitals with excess readmissions. Value-based Purchasing Program, which promotes better clinical outcomes by improving patient experience. And Hospital Acquired Conditions Program, which reduces payments for hospitals with excess hospital acquired conditions. And End-stage Renal Disease Quality Initiative Program, which reduces payment to end-stage renal disease facilities that don't mean established performance standards. The shift to value based payment models has its genesis in the previous fee for service payment models. In fee for service, organizations and providers were being rewarded with financial payments for volume, rather than for value of care. This payment model effectively rewards inefficient care processes through reducing the motivation to coordinate care. Allowing service duplication without any financial penalties, minimizing innovative care processes, and preventing effective management of patients with comorbidities. Value-based payment models are referred to as pay for performance models, and are increasingly becoming the norm in the healthcare industry. With the emphasis on improving healthcare quality, pay for performance supports the Triple Aim. By offering reimbursement incentives for better quality, effectiveness, and efficiency, removing financial incentives for duplicated services. Being data driven and experience based, offering flexibility to customize patient care. Eliminating fragmentation across the care continuum. With pay for performance, there clearly is a financial incentive for healthcare organizations to embrace value-based care. The US Department of Health and Human Services, HHS, announced that by the end of 2016, it aims to link 30% of Medicare reimbursement to quality or value of provider services. And 50% by the end of 2018. In addition to the programs discussed previously, CMS is in the process of rolling out additional value-based models as follows. Newly launched in 2015, the Value Modifier Program is directed at physicians and determines medicare payments based on physician performance on specified quality and cost measures. The Home Health Value Based Programs is currently being piloted. It will give Medicare certified home health agencies, HHAs, incentives to achieve higher quality and more efficient care. 2019 will see the launch of the Skilled Nursing Facility Value Based Program. It will reward skilled nursing facilities with incentive payments quality of care. Following the CMS value based care models, the industry is now seeing a number of private payer coalitions forming to identify similar models. For example, the healthcare transformation task force, a coalition of private payers, providers and employers, pledged to put 75% of it's payments into value based models by January 2020. Finally, as we see an increasing emphasis on quality outcomes in the healthcare industry, the attention to the safety outcomes as affect our influencing outcomes continue to grow. With a Joint Commission establishing national patient safety goals, their regulatory power will help drive safety outcomes as value-based care payments do for quality outcomes. The Joint Commission's multi-pronged approach includes adoption of Computerized Physician Order Entry or CPOE implementation. Standardized disease management protocols, communication skills training, identification and reporting near misses. Near misses are errors that did not actually reach the patient to cause harm. This concludes lecture a of Value-Based Quality and Safety. In summary the intersection between safety and quality and healthcare optimizes care. Value and healthcare is being measured by improved patient outcomes and decreased cost. And the triple aim serves as a foundation for value based care. The government has put in place several significant financial incentives and the private sector is following suit. Healthcare's future lies in delivering value driven healthcare.
