In this episode of Ask Dr. Mingle, Dr. Dan Mingle focuses on value in healthcare, explaining the problem with value in our healthcare system, the role of quality reporting in improving value, and what it means to systematize value. Later, Dr. Mingle explains how to build a quality management system that enhances value.

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Question One: The Problem with Value in Healthcare

Hadley asks: “Do we really have a problem with value in the U.S. healthcare system?”

Yes. We’ve got a big problem.

It’s not always visible from the ground. I’ve nearly been in fist-fights with people who are adamant in their insistence that we have the best healthcare in the world.

I’ve seen this view held by intelligent and observant people who have my respect. They have challenged me to understand the dichotomy.

But you can’t ignore the evidence right in front of us, like:

• High error rates, as exposed in the book To Err is Human written by LT Kohn and published in 2000.
• Data from the Organization for Economic Cooperation and Development (“OEDC”) shows:
  • The per capita cost of healthcare in the U.S. is well above that in any other country.
  • In multiple different measures of the effectiveness of healthcare, the U.S. ranks low against the other members of the OECD.
    • High cost and low effectiveness = low value. We have a problem.
• Data from the Dartmouth Atlas, through which Dr. Jack Wennberg and his associates have published data on unwarranted variations in healthcare experienced in different U.S. communities.
  • There are vast differences in cost and quality of care in our communities, unexplained by differences in demographics, culture, incidence of disease, or other key measures.

In the U.S., we produce a steady stream of advances in the sciences of diagnosis and treatment. But we neglect the science of healthcare distribution.

We are very good at distributing profitable healthcare. But we frequently fail to deliver cost-effective care.

So, yes, excellent healthcare is available and often accessed. But it is poorly distributed and lacks the systemic discipline and error controls that exist in many other U.S. industries.

Question Two: Quality Reporting and Value in Healthcare

Hadley asks: “Is all of this attention to quality reporting doing anything to improve value in healthcare?”

I’ve yet to see significant evidence that it is making a difference, but that’s not to say we should stop.

You can’t increase value in health care with initiatives limited to management of the health care dollar. Healthcare improvement efforts that cut dollars without addressing quality incentivize neglect of complicated, expensive patients.

We have to manage or incentivize low-cost and high-quality, together.

Quality measurement is necessary, but more is needed to build value in healthcare.

And when we anchor the quality measurement infrastructure on a regulatory program, like the Merit-based Incentive Payment System (MIPS), it’s particularly prone to gaming.

I fear that as long as our attention to quality measurement begins and ends with the scope of the regulatory requirements, actual value creation in healthcare will tend to elude us.

Question Three: Systematizing Value in Healthcare

Hadley asks: “I’ve heard you talk about systematizing value before. What do you mean by that?”

Paul Batalden, of the Institute of Healthcare Improvement and the Dartmouth Institute, riffed on a quotation from Arthur Jones when Paul said:

“Every system is perfectly designed to get the results that it gets.”

To get more value out of our system, we have to change our system.

What is the system?

The healthcare system is the sum of its parts. The system includes but is not limited to:

• What healthcare data is collected?
• Who is it collected from?
• Who collects it?
• How is it collected?
• Where and how is it stored?
• How is it accessed?
• How do we recognize the healthcare needs of the met and the unmet varieties?

If we want to do a better job and eliminate errors of omission and commission, we need to build and refine a system to ensure excellent performance.

There are three essential parts to that system:

• People
• Process
• Technology

Your system is the people, processes, and technology that delivers the product and services you want to provide.

• People should be: capable, trained, monitored, and motivated to deliver outstanding care.
• Process should be: documented, followed, and regularly updated to correct observed deficits and to keep up with new medical evidence.
• Technology should be: optimized, using available technology to enable your people to efficiently and effectively deliver your desired processes.

Question Four: Building a Quality Management System that Increases Value

Hadley asks: “How do we build a quality management system that increases value in healthcare?”

The measurement system cannot be merely reactive to the regulatory requirements. It can’t just begin and end with the requirements, whether they are the Merit-Based Incentive Payment System (MIPS) requirements, the APM Performance Pathway (APP) requirements, the Healthcare Effectiveness Data and Information Set (HEDIS), or any other federal, state, or insurer sourced requirement.

In the last question, I defined a system as the people, processes, and technology that deliver on your intentions.

When building your system, remember that your people have to be involved:

• There needs to be a shared understanding of what you intend to deliver to your patients.
  • Think about the essential elements of your product/service.
• Think through the risks or errors your system needs to address.

And your processes need to be documented:

• You should write your processes down – think “policies and procedures.”
  • Your processes should not only be accessible but also routinely accessed. The moment we start relying on memory to keep us on track is when errors start to happen.
• Processes need to be dynamic.
  • When there is awareness of novel errors, update processes to prevent a recurrence. When there is new evidence, update to deliver the new intentions.
• Despite written protocols, your practice should not be in service to the protocols, but the protocols must be in service of your practice.
  • Depart from the protocols when you need to, and update the protocols to address the same need in the future.
• It’s essential that everyone on the team knows where to find your processes and has a hand in creating and updating the process map.

Finally, optimize your use of current technology:

There are three parts to your foundation of technology:

1. A patient portal that allows you to:

• Get input from your patients
• Give output to your patients
• Provide secure and reliable communication
• Don’t think just in terms of a web-based portal, but as a help desk that provides access for your patients how and when they want it. It might include phone access, text messaging, and secure messaging.

2. An Electronic Health Record for:

• Holding data about your patients and your encounters with them
• Efficiently and effectively accessing data about your patients
• Correcting misinformation and tracking changes in understanding diagnoses and treatment plans
• You want fast and effective data entry, as close to the data as possible.
• You want fast and effective data access.
  • And ideally, a standardized, structured language and location for every essential element of data.
• And you want brevity and clarity in the documentation.
  • You should never document anything that is already in the chart.

3. And you need a measurement system to identify met and unmet healthcare needs in your patients:

• There are not, as MIPS or the QPP tend to imply, six measures that define the quality of your care.
  • Medical evidence suggests tens of thousands of individual interventions needed by our patient population.
    • Your system should be able to measure the subset of those evidence-based interventions that apply to your practice.

Keep in mind: there is a vital interaction between your EHR and your measurement system.

Your EHR must hold your best current understanding of the following:

1. The data elements that sort your patients into denominators
2. The data elements that show the met/unmet status of your patients on any intervention you intend to provide
3. And the exceptions or exclusions that apply

Your measurement system must reflect your best current understanding of the desired relationship between denominator elements, numerator elements, and exclusion/exception elements.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

You can leave your questions in a YouTube comment under any episode of Ask Dr. Mingle.

On LinkedIn, leave your questions in a comment on any of our posts.

And you can reach out directly by sending an email to hello@minglehealth.com.