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Like me you’ve probably lost count of the number of articles you’ve read that discuss the theory of improving value in health care delivery. This isn’t another one of them! This instead is an insight to ‘on the ground’ practice that’s making a real difference and might hold some learning for us all.

With multiple Vanguard Pioneers now established in England there is a real sense of anticipation about the future of Health and Social Care delivery. As organisations and systems embark on change, there’s a sense of where to start and how to establish new forms of governance and ways of working that will enable change?

In our dialogue with system leaders we have been developing a conversation with one particular company – Lumeris. Their focus on Clinical Leadership and the development of senior decision makers who understand the need to think and behave at both a system level and a local level to deliver better value and improved patient outcomes is key in any country and any language. The big question is ‘How’ do you do that? Well before we head out to our Local Authority colleagues in the UK to engage in whole system discussions we need to check out that we’ve got the Clinical Leadership already engaged. Lumeris recognised early the need to do two important things:

  • Make the value based clinical decision the ‘Right thing to do’ on every occasion
  • Make the right thing to do the ‘Easy thing to do’ on every occasion

Their experience in working across a population of over 2 million is that this requires a change in mind set and behaviour that must be Clinician led and through which they and their teams are incentivised to get it ‘right’ for the patient and the tax payer every time. Focusing on the shared care record; making use of the data to provide meaningful, actionable information at all levels of the care team; and developing shared ‘risk/reward’ strategies for managing better outcomes in defined population sub-groups produces better results all round. This care delivery shift isn’t possible without a significant shift from all parties in the creation of new business models that enable triple aim plus one focused care, performance improvement and sustainability. Lumeris’ experience has been that clinicians working within an environment of ‘value based compensation’ are seeing much better returns by changing the healthcare spending patterns and focusing on the early years of illness with big benefits seen as the population ages and their disease burden grows.

Exhibit graph

 

This is the period of time when traditionally we see health care costs soar with increased episodic nature of treatment accompanying the ageing and advanced disease processes. This can be curtailed however, if resources and incentives are decentralized to local care teams- where patients are known, managed and cared for better over time. Terrarium Of course, that also means a balancing of financial benefit within the clinical system for the GP and Hospital alike!

Being more planned in their approach and pro-active in their intervention with patients means a change away from the ‘Cafeteria’ model of the present where you turn up and get something to a better ‘workflow’ for everyone. It also brings with it a tremendous development opportunity where all accountable care team members can practice to the upper limits of their capabilities and licenses. Fundamentally it is about aligning the clinical and the business model and then providing the right people, process, methodology enabled by best in class technology in order to execute on both models in an integrated fashion.

Since the patient-GP relationship is at the heart of many of the care decisions made, a focus on provider satisfaction/engagement is a key addition to Don Berwick’s and IHI’s Triple Aim. The GP must be seen as the person ultimately responsible for the coordination of an attributed patient’s care, realizing they have a full care team surrounding them to enable proactive, high value care. In this case, value is defined as quality/cost, and the balance of the economic incentives need to drive the delivery of high value care over time and at all stages of health and sickness across a population. This manifests itself in several ways:

  • Proactively and regularly seeing patients with chronic diseases to prevent an acute illness.
  • Providing gaps in evidence based care and cost saving alternatives to the point of care.
  • Stratification of the population for enrolment in quality and care management programs, shown to reduce hospitalizations and improve chronic disease management over time.
  • Encouragement of competition among hospitals and specialist physicians to provide and deliver the highest value care to the largest portions of the population.
  • All members of the care team practice to the utmost heights of their capabilities and scopes of practice (e.g. a scheduler being cross trained as a health coach).

 

The proof is in the pudding. In theory, all of these activities sound great, but do they really work? In short, absolutely yes. In the Lumeris model, as evidence by data from their client Essence Healthcare- which is entirely run by Lumeris, the collaborative GPs and their teams that participate in the value based care of over 52,000 seniors, have showcased the following results:

  • 5-star Quality as measured by HEDIS (among the top 2.5% in the country)
  • Total cost of care has been reduced by 30%*,
    • Cost of acute care (↓ 38%) and admissions (↓ 11.3%),
    • Readmissions (↓ 18%),
    • Specialist physicians cost (↓ 40%)
    • The specialists and hospitals that deliver the highest value of care and get the highest number of referrals from the GPs
  • Member/Patient satisfaction is also at 5-Star as measured by HEDIS
  • Physician satisfaction is high (80% consistently rate satisfaction) based on survey data

*Compared to matched sample of Fee for Service Medicare Patients and validated by Aon

The physicians and their leadership/care teams frequently meet with the Lumeris team in joint operating committees to review evidence based best practices, identify trends in the data, and share ways to operationalize and provide triple aim plus one focused care.

These principles and practices have also proven themselves effective in other populations across the United States, including the commercial marketplace, which focuses much of it’s attention on all ages of the working class. We believe this same level of care delivery change and business model change can positively impact the NHS and care delivery across the United Kingdom, but it will take both to be truly effective.

The conclusion of this insight is that early intervention realises real benefits if you can target the populations who receive that care and ‘do the right things’ consistently well. Such strategies rely on good data management and most importantly, sharing of information across all team members. Primary Care and Hospital clinicians need to see that it makes financial sense to operate in this way and that means that risk must be shared across the whole of the patient pathway. Accountability for Care and indeed, Self Care by the population can only occur where there is clarity about expectations and everyone shares their part of the responsibility in making the right things happen. These though are the facets of Health Systems acting in concert rather than individual teams competing or avoiding. They suggest not only good information flows but also clear clinical leadership across the care continuum, in which the power to do good is shared and round table discussion of outcomes supersedes contractual divisions. There are good examples in the UK moving toward this goal and we need to explore how we can accelerate that process by learning from others no matter which payment system they have been operating in. It’s behaviour that determines the altitude of ambition not money!

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