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Regional Framework: Introduction

It helps to have a “System”
Recent evidence indicates that some Americans benefit from better care. Large health systems such as the Veteran’s Health Administration and Kaiser Permanente have significantly improved  the quality of their care for their millions of patients (ref). How did they do it and, more importantly, is their experience relevant to the rest of American medical care? Studies of these high performing health systems tend to agree on the following predictors of success:
  • Strong leadership committed to quality improvement;
  • Shared vision among clinicians and “business” folks;
  • Routine measurement of the quality and costs of care;
  • Emphasis on primary care and its integration with specialty care;
  • Evidence-based guidelines integrated into performance measurement and clinical decision-making;
  • Information technology that facilitates performance measurement, and provides decision support for clinical care; and
  • Organized quality improvement activities.
Of course, this raises the question of what can be done for those people who are not part of a large, high performing system?  A growing number of places in the United States, are exploring broad-based, geographically focused improvements to the community’s healthcare infrastructure.  We have been examining the success stories among these coalitions, and seeing what common lessons can be drawn about how they are formed and the work they do.  Detailed reports on what we have found to date can be read here, what follows is a brief and general overview of the constituent parts of successful healthcare coalitions.
The Framework for Creating a Regional Healthcare System
The experience of community-based efforts to improve health and healthcare, complemented by that of successful large organizations, leads us to propose a framework for improving the quality and efficiency of healthcare for a geographically defined population.  The proposed Framework and its specific components are not evidence-based, as rigorous research evaluating the impacts of regional initiatives and the proposed components on regional quality, health outcomes, and costs has been very limited.  In fact, some of the elements mentioned in the Framework - such as public disclosure of performance data - remain controversial, at best.  Therefore, the proposed Framework is descriptive and heuristic, a compendium of important local responses to the major problems and trends in current American healthcare

The Framework might be best explained from the bottom up.  The overall goals of the structure and activities described in the Framework are to:
  • improve the quality of care and outcomes  across a population, especially for those with a chronic illness; and
  • reduce the costs of care for that population through waste reduction, outcome improvement, and greater administrative efficiency. 
These ambitious goals will not be achieved without major redesign of our current care delivery systems, small and large.  So, transformation or redesign of healthcare delivery in accord with the Quality Chasm aims is an essential intermediate outcome.  Such broad scale delivery system changes are unlikely without direct support of practices and active programs of practice change, and changes to benefits and provider payment to make them more conducive to system change.  It is also entirely possible that consumer encouragement of cost-effective care through advocacy and purchasing will accelerate change.
All three strategies benefit from the pooling of clinical and cost data to support clinical care and for performance measurement.  In most communities, data on clinical performance are mostly limited to what’s available in claims, and tightly held by each major provider organization, health plan or self-insured employer.  Aggregate measures of quality or efficiency in the community, or by individual providers are generally missing, and clinical data on individual patients reside in disconnected provider record systems.  The Framework reflects the fundamental role of pooled clinical data and performance measurement in creating a regional healthcare system with the capacity to improve.  Providers would have feedback on their performance and the prospect of financial incentives, as well as improved access to and breadth of clinical data for patient care.  Purchasers and insurers would have access to complete data on their network providers to guide payment and quality improvement activities.  Consumers would have information on the performance of various community providers, and their full medical record could be available wherever they receive care.
The Framework identifies three key sets of stakeholders in transforming care—consumers, providers, and purchasers/health insurers.  The values and objectives of these three actors are not necessarily in alignment in typical American healthcare marketplaces without intervention.  There needs to be an entity that convenes the three stakeholder groups, finds common ground, and provides leadership and direction.  The literature on community health programming repeatedly gives emphasis to the importance of a shared vision and mission across the various stakeholder groups, and leadership that can make collaboration work. 
Providers must have the clinical data systems, quality improvement strategies, and infrastructure to motivate and support the redesign of their delivery systems.  Practice information systems, at the very least, should furnish clinicians with: critical clinical information on key patient groups; reminders of needed services; and measures of quality and improvement (registry functions).  Practice redesign is daunting, especially with proven models and quality improvement activities (e.g., collaboratives, practice coaches, problem-based learning).  Consensus, evidence-based guidelines help focus measurement and quality improvement activities, and practices need access to care management and self-management support resources.  Finally, the improvement experience of the Veteran’s Health Administration generated a model for spreading system change that emphasizes the importance of social networks in the process of diffusion. The growing isolation of small, primary care practices from traditional social and educational settings such as hospitals appears to be a barrier to the spread of system change, and the development of physician networks that provide programs and infrastructure locally may be a solution. 
While delivery system redesign is largely the work of motivated, prepared healthcare professionals, many believe that more informed and actively engaged consumers, through their purchasing and care decisions, can induce healthcare systems to improve and become more efficient.  Public disclosure of performance data is widely recommended although there has been little if any demonstration of impact on consumer behavior.  Purchasers are clearly shifting costs to consumers.  While we lament the increased financial burden on consumers, cost-sharing strategies that increase consumer involvement in decisions about their care may encourage more cost-effective care and reduce unwarranted, supply-driven demand.  Strategies to increase the use of effective generic drugs are a prime example.
Removing some of the disincentives, redundancies and inefficiencies in current health insurance and payment should reduce costs as well as encourage a transformation of care, especially if accompanied by incentives for improvement.  Financial incentives based on performance are viewed, along with information technology, as the saviors of American healthcare.  As mentioned above, benefit designs that provide incentives to consumers and providers to deliver evidence-based services may contribute to higher quality.  Standardization of processes for performance measurement and claims management could reduce administrative demands on practice settings and contribute to better data quality.
Will the success of a regional improvement effort depend upon its implementation of all or most elements in the Framework, as has been the case with the Chronic Care Model? While the elements and strategies described in the Framework appear to be complementary, there is not sufficient evidence currently to even begin to answer this question. 
Putting it all together
The strategies described here are linked. A successful program in regional healthcare cannot exist in the absence of strong leadership and cooperation among those with the money and risk - those providing care and those receiving care. Performance measurement is essential for public disclosure and pay for performance, and a crucial tool for practice improvement. As a guide to regional healthcare improvement, we have tried to organize the strategies in this Framework.  The goals are to improve the quality of care and reduce costs, which do not appear to be contradictory. The IOM makes clear that nothing short of major transformation of our current delivery systems will close the quality chasm, the gap between care as usual and best practice.
There is insufficient evidence at present to delineate the essential features of an effective regional improvement program. Do you need activities in all areas or just a few? We believe that the four strategies—performance measurement, engaging consumers, supporting delivery system improvement, and aligning benefits and payment—are synergistic. If the IOM Quality Chasm report is correct, then effective regional programs would both change the financial and information technology environments to be more supportive of care improvement, and help providers redesign their care systems to better meet the needs of patients.