Few clinicians have any knowledge of what each component of care costs, much less how costs relate to the outcomes achieved. In most health care organizations there is virtually no accurate information on the cost of the full cycle of care for a patient with a particular medical condition. Instead, most hospital cost-accounting systems are department-based, not patient-based, and designed for billing of transactions reimbursed under fee-for-service contracts. In a world where fees just keep going up, that makes sense. Existing systems are also fine for overall department budgeting, but they provide only crude and misleading estimates of actual costs of service for individual patients and conditions.
For example, cost allocations are often based on charges, not actual costs. As health care providers come under increasing pressure to lower costs and report outcomes, the existing systems are wholly inadequate. Existing costing systems are fine for overall department budgeting, but they provide only crude and misleading estimates of actual costs of service for individual patients and conditions.
To determine value, providers must measure costs at the medical condition level, tracking the expenses involved in treating the condition over the full cycle of care. Then the cost of caring for a condition can be compared with the outcomes achieved. While rarely used in health care to date, it is beginning to spread. Where TDABC is being applied, it is helping providers find numerous ways to substantially reduce costs without negatively affecting outcomes and sometimes even improving them.
In light of those cost differences, focusing the time of the most expensive staff members on work that utilizes their full skill set is hugely important. Without understanding the true costs of care for patient conditions, much less how costs are related to outcomes, health care organizations are flying blind in deciding how to improve processes and redesign care.
Clinicians and administrators battle over arbitrary cuts, rather than working together to improve the value of care. Neither of the dominant payment models in health care—global capitation and fee-for-service—directly rewards improving the value of care.
It also decouples payment from what providers can directly control. Fee-for-service couples payment to something providers can control—how many of their services, such as MRI scans, they provide—but not to the overall cost or the outcomes. Providers are rewarded for increasing volume, but that does not necessarily increase value. The payment approach best aligned with value is a bundled payment that covers the full care cycle for acute medical conditions, the overall care for chronic conditions for a defined period usually a year , or primary and preventive care for a defined patient population healthy children, for instance.
Well-designed bundled payments directly encourage teamwork and high-value care. Payment is tied to overall care for a patient with a particular medical condition, aligning payment with what the team can control. Providers benefit from improving efficiency while maintaining or improving outcomes. Sound bundled payment models should include: severity adjustments or eligibility only for qualifying patients; care guarantees that hold the provider responsible for avoidable complications, such as infections after surgery; stop-loss provisions that mitigate the risk of unusually high-cost events; and mandatory outcomes reporting.
Governments, insurers, and health systems in multiple countries are moving to adopt bundled payment approaches. For example, the Stockholm County Council initiated such a program in for all total hip and knee replacements for relatively healthy patients. The result was lower costs, higher patient satisfaction, and improvement in some outcomes. In Germany, bundled payments for hospital inpatient care—combining all physician fees and other costs, unlike payment models in the U.
Among the features of the German system are care guarantees under which the hospital bears responsibility for the cost of rehospitalization related to the original care. Here, mandatory outcomes reporting has combined with bundles to reinforce team care, speed diffusion of innovation, and rapidly improve outcomes. Providers that adopted bundle approaches early benefitted. Employers are also embracing bundled payments. The hospitals are reimbursed for the care with a single bundled payment that includes all physician and hospital costs associated with both inpatient and outpatient pre- and post-operative care.
Employees bear no out-of-pocket costs for their care—travel, lodging, and meals for the patient and a caregiver are provided—as long as the surgery is performed at one of the centers of excellence. The program is in its infancy, but expectations are that Walmart and other large employers will expand such programs to improve value for their employees, and will step up the incentives for employees to use them.
Sophisticated employers have learned that they must move beyond cost containment and health promotion measures, such as co-pays and on-site health and wellness facilities, and become a greater force in rewarding high-value providers with more patients. As bundled payment models proliferate, the way in which care is delivered will be transformed. For example, many hospitals routinely have patients return to see the cardiac surgeon six to eight weeks after surgery, but out-of-town visits seem difficult to justify for patients with no obvious complications.
In deciding to drop those visits, clinicians realized that maybe local patients do not need routine postoperative visits either. Providers remain nervous about bundled payments, citing concerns that patient heterogeneity might not be fully reflected in reimbursements, and that the lack of accurate cost data at the condition level could create financial exposure.
Those concerns are legitimate, but they are present in any reimbursement model. Providers will adopt bundles as a tool to grow volume and improve value. A large and growing proportion of health care is provided by multisite health care delivery organizations. Those proportions are even higher today. Unfortunately, most multisite organizations are not true delivery systems, at least thus far, but loose confederations of largely stand-alone units that often duplicate services. There are huge opportunities for improving value as providers integrate systems to eliminate the fragmentation and duplication of care and to optimize the types of care delivered in each location.
To achieve true system integration, organizations must grapple with four related sets of choices: defining the scope of services, concentrating volume in fewer locations, choosing the right location for each service line, and integrating care for patients across locations. Is relocating service lines on the table?
A starting point for system integration is determining the overall scope of services a provider can effectively deliver—and reducing or eliminating service lines where they cannot realistically achieve high value. For community providers, this may mean exiting or establishing partnerships in complex service lines, such as cardiac surgery or care for rare cancers. For academic medical centers, which have more heavily resourced facilities and staff, this may mean minimizing routine service lines and creating partnerships or affiliations with lower-cost community providers in those fields.
Although limiting the range of service lines offered has traditionally been an unnatural act in health care—where organizations strive to do everything for everyone—the move to a value-based delivery system will require those kinds of choices. Second, providers should concentrate the care for each of the conditions they do treat in fewer locations.
Concentrating volume is essential if integrated practice units are to form and measurement is to improve. Numerous studies confirm that volume in a particular medical condition matters for value. Providers with significant experience in treating a given condition have better outcomes, and costs improve as well. Patients, then, are often much better off traveling longer distance to obtain care at locations where there are teams with deep experience in their condition.
That often means driving past the closest hospitals. Organizations that progress rapidly in adopting the value agenda will reap huge benefits, even if regulatory change is slow. Concentrating volume is among the most difficult steps for many organizations, because it can threaten both prestige and physician turf. Yet the benefits of concentration can be game-changing.
In , the city of London set out to improve survival and prospects for stroke patients by ensuring that patients were cared for by true IPUs—dedicated, state-of-the-art teams and facilities including neurologists who were expert in the care of stroke.
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These were called hyper-acute stroke units, or HASUs. At the time, there were too many hospitals providing acute stroke care in London 32 of them to allow any to amass a high volume.
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UCL Partners, a delivery system comprising six well-known teaching hospitals that serve North Central London, had two hospitals providing stroke care—University College London Hospital and the Royal Free Hospital—located less than three miles apart. University College was selected to house the new stroke unit. Neurologists at Royal Free began practicing at University College, and a Royal Free neurologist was appointed as the overall leader of the stroke program. These steps sent a strong message that UCL Partners was ready to concentrate volume to improve value.
The number of stroke cases treated at University College climbed from about in to more than 1, in All stroke patients can now undergo rapid evaluation by highly experienced neurologists and begin their recovery under the care of nurses who are expert in preventing stroke-related complications. The third component of system integration is delivering particular services at the locations at which value is highest. Less complex conditions and routine services should be moved out of teaching hospitals into lower-cost facilities, with charges set accordingly.
There are huge value improvement opportunities in matching the complexity and skills needed with the resource intensity of the location, which will not only optimize cost but also increase staff utilization and productivity. More recently, the hospital applied the same approach to simple hypospadias repairs, a urological procedure.
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Relocating such services cut costs and freed up operating rooms and staff at the teaching hospital for more-complex procedures. In many cases, current reimbursement schemes still reward providers for performing services in a hospital setting, offering even higher payments if the hospital is an academic medical center—another example of how existing reimbursement models have worked against value.
But the days of charging higher fees for routine services in high-cost settings are quickly coming to an end.