Architecture of high value health care

As the US works to improve health care value, a strategic plan is essential to ensure the quality, safety, and effectiveness of a new model for health care delivery. “Value” has been defined in various ways, with costs as the universal denominator. Quality, patient safety, and patient experience are key elements of the numerator, underscoring the importance of quality-driven care refinement and systematic analyses to measure both safety outcomes and patient satisfaction. To effectively refine medicine, quality improvement efforts must be implemented across 5 pillars:

  1. Diagnostic and therapeutic efficiency: Eliminate unnecessary imaging, labs, telemetry, medications, procedures etc. In addition to costs, these elements of practice carry risks and/or may lead to more unnecessary downstream testing. The Choosing Wisely® Campaign has championed this work by engaging patients in decision-making, as directed by nearly 500 recommendations from 75 medical societies. Innovative diagnostic tests that provide greater sensitivity and specificity are equally important, such as liquid biopsies and molecular imaging agents to detect cancer in the early stages, as well as imaging tests that can reliably distinguish benign tumors from malignancies and eliminate the need for unnecessary surgeries.
  2. Quality-driven care pathways: Specialty-designed, quality-driven inpatient and outpatient practice pathways to decrease the variabilities that reduce efficiency and unnecessarily increase cost. Evidence shows that pathways improve outcomes and reduce length of stay.
  3. Discharge transitions: Improving patients’ understanding of how to manage their care and access to outpatient resources will decrease preventable readmissions.
  4. Optimizing patient care setting: Specialized outpatient acute care centers (oncology for example) to reduce emergency department visits and maintain continuity with the primary care team. Additional successful initiatives include outpatient parenteral medication administration to reduce length of stay and inpatient palliative care units.
  5. Preventative medicine: promoting a healthy lifestyle to reduce the risk of disease, evidence-based screening tests for early diagnosis, and adherence to preventative care guidelines (e.g. VTE prophylaxis for inpatientspreventing catheter associated UTI).

While many different organizations are contributing to these efforts, the transition will only be successful if medical providers become accountable for improving the value of the care they deliver and join the charge to advance value-based quality-improvement. In the words of Richard Duszak, MD, Director of Health Policy and Practice in the Emory Department of Radiology, “Real innovation will only come from the ground up – from doctors and nurses and patients, and everyone else in the trenches.”

As such, providers in all specialties are reflecting on their practice to identify opportunities, implement initiatives and improve quality in these 5 areas. Hospitalists have been doing exemplary work, as described by Moises Auron, MD at Cleveland Clinic and member of the Society of Hospital Medicine“We can recognize areas where unnecessary expenditure is used by having a lean mind and focusing on removing waste that will not impact our patients. We are the experts on the front line—we need to share the feedback to the leadership.”

Similarly, radiologists need to play a role in all aspects of their care, including appropriateness of patient selection for imaging, performing the best imaging test for each clinical indicationprotocol selection and technological advancements to deliver the most information at the lowest cost, and reports that add valuable patient management information without recommendations for unnecessary workups. The success of initiatives to improve imaging appropriateness hinge on cross-specialty engagement, to create consensus guidelines and mutually acceptable clinical decision support interventions for advanced imaging, as mandated by CMS. The American College of Radiology R-Scan Program is designed for cross-specialty value improvement.

Providers in all medical specialties are summoned to join the charge. Venues to participate in organized efforts include the High Value Practice Academic AllianceCosts of Carethe Lown Institute, and Providers for Responsible Ordering. Medicine is a public trust, and to ensure that this trust is not broken, medical providers, hospitals, and health systems need to become uniformly accountable for practicing high value health care.