10 Steps to Better Health Care And Controlled Costs

Dr. Don Goldmann is Senior Vice President of the Cambridge-based Institute for Healthcare Improvement, Professor of Immunology and Infectious Diseases, and of Epidemiology, at the Harvard School of Public Health, and Professor of Pediatrics at the Harvard Medical School.

He submitted testimony for this week's state hearings on cost control and offered a 10-step plan to address shortcomings in the current system:

Massachusetts has tackled the issue of access to health care and now faces the challenge of providing better care while controlling costs. Fortunately, both are possible, but they will require a series of systems improvements. Here are 10 steps that are particularly important, along with some caveats and cautions. They should be applied throughout Massachusetts – and across the nation, no matter what happens with health care reform in Congress.

1. Improve patient safety and reduce harms. Great progress has been made in reducing the rate of costly infection in hospitals, but there still is room for improvement. Hospitals must also continue to address other avoidable harms, such as pressure ulcers, falls, and adverse drug events.

While focusing on individual harms certainly is beneficial, it is inefficient and may have significant opportunity costs by shifting hospital resources from other quality and safety issues. Harm prevention needs to be addressed as a system property – part of a broader effort to transform the way we work so that the overall rate of harm and mortality declines. Patients want to know that they will be safe and will have no harm in the hospital; period. They don’t want or need to pay attention to multiple types of adverse events.

Prevention must also extend beyond the hospital walls, especially following discharge from the hospital, and errors of commission are no less important than errors of omission. A 60-year- old patient who did not receive an indicated colonoscopy and presents with colon cancer, and a patient who has a wound infection following colon cancer surgery, both have suffered terrible harms.2. Reduce avoidable hospitalizations, re-hospitalizations, and emergency department visits. The Commonwealth is taking a leadership role in addressing these issues, especially re-hospitalizations, but significant challenges remain. Maximum benefit will be achieved, for instance, only if patients – especially those with complex medical and social problems – are supported across the continuum of care. Yet, currently, neither hospitals nor primary care providers are rewarded for avoiding re-hospitalizations.

And many patients will need additional support from health coaches and community services outside of the hospital. Some of this assistance can be provided by trained individuals who are not highly paid health care professionals, especially if we leverage technologies such as home monitoring devices and alert systems.

Most chronically ill patients would rather be in their homes, with the support they need, than in a nursing home or hospital, and systems improvements should support that preference wherever possible. The Patient-Centered Medical Home is a partial answer but by itself cannot be expected to magically support patients at home and across the care continuum without other supports. Realizing the promise of the medical home will require payment reform and a shift in resources to ambulatory and community-based services.3. Reduce overuse of drugs and technologies, particularly by specialists. Even though terms such as “overuse” and “waste” are distasteful to providers and often misunderstood by patients, the evidence for unacceptable variation and overuse of diagnostic and therapeutic modalities is very clear.

Current comparative effectiveness research methods, which rely largely on randomized trials, are unlikely to help us sort out which technologies are most cost-effective. Progress is too fast, and the trials are too expensive and take too long. We will need to shift our efforts to data mining of rich, interoperable, clinical datasets.

Based on the Heller School data, there also appears to be an urgent need to understand the relationship between price and cost in Massachusetts. Addressing the impact price increases have had on health care costs, especially in hospital outpatient settings, is critical. Focusing only on utilization seems problematic; variation in pricing is at least as striking. Health care seems to be a unique industry in which increased supply fuels increased demand, without much impact on price.4. Reduce waste in the entire health care system by streamlining systems using lean techniques, reliability science, or other disciplined methods. Spend one day on the ward of any hospital and you will see waste and redundancy everywhere – unused drugs poured down the drain, duplicate tests performed because specimens were lost, redundant antibiotics administered and radiological procedures performed. But even worse are time wasted by providers and patients and delays in receiving appropriate care. Equally pernicious is wasting the will, energy, and ideas that our providers bring to work every day.5. Deploy Health Information Technology (HIT) at scale. There is abundant evidence that HIT can reduce cost and improve quality of care; however, to achieve meaningful use and improved clinical outcomes, HIT implementation must be complemented with clinical systems redesign. In addition, more attention should be paid to the true costs of sustaining clinical decision support systems in light of rapidly evolving advances in diagnostics and therapeutics and changing guidance from clinical effectiveness research. We should also consider designing HIT systems from the perspective of patients rather than providers.6. Test innovative regional solutions to improving quality of care, improving health, and controlling per-capita costs. Pay special attention to the health component, which often is considered in a silo since the time horizon for pay-offs from prevention and health promotion generally is far longer than the usual fiscal horizon. Calculations of health care costs should include other critical investments needed to improve health – improvements in the built environment, community services, sanitation, food, etc.7. Accelerate tort reform. The evidence indicates that physicians often are practicing defensive medicine when they order tests or procedures that are not evidence-based.8. Think of health and health care expenditures as coming from a common resource pool. Ultimately, these costs are borne by the individuals living in a community, but citizens do not tend to think about health care in this way. Opinion leaders should mobilize the public to think differently about the consequences of unsustainable increases in health care costs for them and their children.9. We need more emphasis on the “how” of getting from here to there. I doubt that we will achieve our goals magically through legislative mandates, public reporting, pay-for-performance, or free market forces. Providers and patients are going to need coaching on how to achieve these aims.10. Every potential solution we develop must respect the safety net and the needs of the underserved. Disparities in access, quality of care, and health promotion and diseases prevention are unacceptable.