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Creating a New UH Model for Improving Value in Health Care

UH Clinical Update - December 2018


By Cliff Megerian, MD, President, UH Physician Network and System Institutes,
  and Peter Pronovost, MD, PhD, Chief Clinical Transformation Officer


The word “value” is used so often in business that it verges on meaningless.

But when we use it in health care, value has a very specific definition: it means the total benefit delivered to a patient as it relates to safety, quality and satisfaction.

Think of it as a fraction: Safety plus quality plus satisfaction, divided by annual total cost of care. For us, value is not a buzzword – it is a metric that health care systems are being measured on, ever more rigorously. So we must provide the highest value to patients, as well as to insurers and employers.

Hands down, one of the most obvious and immediate ways for us to control costs is to keep patients within our system. We know that at UH, our costs and fees are competitive, and nearly always lower than they would be at other systems. That’s one reason it’s crucial to keep patients here and not refer them out. Other benefits include eliminating a lack of duplication of tests or treatments and preventing needless treatments and complications that can arise, including drug interactions.
We know that leads to fewer readmissions. And if palliative or hospice care are required, we provide that instead of performing fruitless procedures or interventions.

Safety and quality and patient satisfaction create the best care. Now I will turn over the next part of this blog to Dr. Peter Pronovost, our new UH Chief Clinical Transformation Officer. He is a world-renowned expert on value and quality, and I wanted him to share his vision for cost, quality and safety at UH.

Dr. Pronovost:

Health care performs miracles every day, yet the same system is estimated to waste 30 cents out of every dollar on things that don’t get people well or that could be used more effectively.

As a result, health care hurts people’s budgets, employers’ budgets and state and federal budgets.
Health systems must take the lead in finding out how to give better value, and that is what we are embarking on here at UH.

As Dr. Megerian noted, we define value as quality plus safety plus patient experience over cost. And the best and biggest way to drive value is to make health care work like a system – defined as parts interacting to achieve a goal.

UH has all the necessary parts. But what we want to do now is align around a goal – in other words, to hardwire the connections among the parts.

Our goal is to make UH really work as a system to be the leader in value. So how will we do that?

Some of the crucial elements driving value include how well we help our patients stay well, get well and manage chronic and acute conditions.

Helping them stay well means making sure patients get the preventive services they need, such as immunizations and cancer screenings.

We also want to address the social determinants of their health. Can patients afford their medication? Can they get transportation to their physician’s office? Do they know how to move toward healthier habits, such as eating fresh food, exercising and finding ways to reduce stress?

Helping patients get well is making sure we assist them in managing chronic diseases or conditions, such as hypertension, diabetes and depression.

But first we need to know we have accurately diagnosed patients – because in many people, these conditions go undiagnosed. Once they are diagnosed, are they getting the appropriate therapy? Can they afford their prescriptions? Do they have access to the doctor and pharmacy?

If they do, then their symptoms or physiology can be controlled, and their use of health care is reduced. That’s good for them and for us, because now we and all health care systems are being measured on metrics of population health.

This is why we want to create a new narrative, one that keeps patients healthy at home rather than healing in a hospital.

We also need to help people manage an acute condition. If a patient develops an acute condition, we need to ensure that everywhere on that patient’s journey, their care is coordinated with the patient’s primary care physician. Excellent patient care is anchored in primary care and when it is, it’s far more likely the patient is seen at the most appropriate site. We don’t want patients in the ED or the hospital for something that could be treated at an ambulatory center, or at Urgent Care for something that could be managed at home through UH telehealth.

High value means providing the best quality and patient experience at a lower cost – for those who receive the care, and for those who pay for it. Many decisions to use UH are made by employers through insurance contracts, so we have to drive value for them, too.

That’s why keeping care inside the network is so important. We cannot accomplish any of the above if we don’t know where or even if care is delivered. When we don’t get the patient’s records or data, we can’t manage their care in a high-value way.

In some of my prior work to reduce infections, what really created the reduction in hospital-patient infections from central lines was that clinicians started telling a new story. They used to say, “These infections are inevitable and they just happen when you care for sick patients.” What got us to zero infections was when clinicians started saying, “These infections are preventable and I am capable of doing something about it.”

Benchmarks had anchored us to poor performance. Everyone just aimed for the average, not for zero infections – even when ‘average’ was people using best practices only 30 percent of the time.

Then the belief, the story, changed: When we followed best practices 100 percent of the time the benchmark became zero infections.

We need to view defects in value with the same vigor.

Right now, about half of patients get the recommended immunizations or cancer screenings. And we accept that, instead of saying it is a defect. Most patients with chronic diseases are not appropriately or optimally managed. That is also a defect that many have come to accept – but it leads to patients unnecessarily visiting the ED several times a year.

The opportunities for us to drive value abound. But they will only be realized if every one of us at UH works together to make this happen.

Though this work and the term “value” as used in health care is new, the way we will be successful is old.

It is the UH tradition, and what we were founded on: excellence, discovery, teamwork and compassion.