The Health Care Delivery System: A Blueprint for Reform

Overview and Recommendations (pdf)

Full book (pdf)

Introduction (pdf)
Meredith King Ledford, M.P.P.; Jeanne M. Lambrew, Ph.D.; David J. Rothman, Ph.D.; and John D. Podesta, J.D.

Chapter One: Workers, Tools, and Knowledge: The Infrastructure for Delivery System Reform (pdf)
David Blumenthal, M.D., M.P.P. and Karen Davenport, M.P.A.

Chapter Two: The Organization of Health Care Delivery: A Roadmap for Accelerated Improvement (pdf)
Thomas H. Lee, M.D., MSc. and Robert A. Berenson, M.D.

Chapter Three: Quality of Care (pdf)
Donald Berwick, M.D., M.P.P., F.R.C.P. and Chiquita Brooks-LaSure, M.P.P.

Chapter Four: Provider Payment Incentives and Delivery System Reform (pdf)
Paul B. Ginsburg, Ph.D.

Chapter Five: Second-Generation ConsumerIsm: Increasing Consumer Activation to Improve Health Outcomes and Lower Costs for Patients with Chronic Disease (pdf)
Judith Hibbard, Dr.P.H., M.P.H. and Katherine Hayes, J.D.

Chapter Six: An Agenda to Improve the Health of the Public (pdf)
Steven A. Schroeder, M.D. and Dora L. Hughes, M.D., M.P.H.

Author Biographies

Acknowledgments

Overview and Recommendations

Concern about the state of the American health care system has reached a slow boil. Health care consistently ranks among the top three issues that the American public wants policymakers to address, and it is increasingly intertwined with growing worries about economic insecurity. High costs, gap-ridden coverage, and sporadic quality are the health care problems that most concern Americans. Yet most of the policy discussion is focused on the issue of coverage.

To ensure that the other problems are not forgotten and that delivery system reform is central to any plan, the Center for American Progress and the Institute on Medicine as a Profession partnered to develop the book, The Health Care Delivery System: A Blueprint for Reform. In the health policy arena there is a dearth of specific policy recommenda¬tions to improve the delivery system. Yet these ideas are often disconnected from the current system, with no policy path¬way, backed by leadership and organization, to get from here to there.

This book offers recommendations and path¬ways to systematically promote quality, efficiency, patient-centeredness, and other salient characteristics of a high-performing health system. The blueprint it lays out is a vision of how different parts of the system should be structured and how they should function. Even more specifi¬cally, it proposes policies that the next administration and Congress could enact over the next five years to improve our health system. Different areas of focus in the book include:

Infrastructure: Health care depends on a highly trained, balanced, and motivated workforce; current and accurate information; and technologies that enable health professionals to use information in the right place, in the right way, and at the right time. People, knowledge, and the means for their application are the founda¬tion upon which an efficient, high-quality health system rests.

Organization: The most effective way to address our cost and quality challenges is to confront the root cause—the chaos in everyday health care. Efforts should focus on accelerating the organization of health care providers into team-like configurations so that they can adopt systems that are likely to reduce errors of overuse, underuse, and misuse, and improve the overall coordination of care.

Quality: Improving the quality of services delivered is paramount to enhancing health system performance. Currently, an apparent contradic¬tion exists between the fact that the United States has the highest quality health care in the world, yet also has a quality “chasm.” To truly improve the quality of the health care delivery system, policies must focus on the individual and population level.

Payment reform: Provider payment structures play an important role in how well the health care delivery system meets the goals of delivering efficient and high-quality care. Policies must work to align the desires of practitioners and health orga¬nization managers to serve patients with the incentives that come from how they are paid.

Patient activation: Polices on the demand side of the equation must focus on how best to engage individuals in their own health and care. This is increasingly important in the face of a growing chronic disease epidemic.

Population health: Improving the health care delivery system is key to improving the health of all Americans. Even if the access, quality, and cost problems in the medical system are resolved, a traditional view of the delivery system must expand to include population-wide programs in order for the system to reach its full potential.

The signs that such a debate could take place in the near future are strong. Both presidential can¬didates have proposed to reform the health care system, demonstrating the polit¬ical ripeness of the issue. When that opportunity presents itself, it will be essential to be ready with grounded policies that are more than patches and can serve as pathways toward a high-performing health system.

Infrastructure

Health information technology

• Promote the use of electronic health records through grants and loans to selected essential health providers.
• Provide federal matching funding to states and localities to create local information exchange networks.
• Direct action to safeguard the privacy of electronic health information.

Workforce

• Invest in scholarship and loan repayment programs for newly trained health care providers.
• Boost capacity in nursing education through a mix of new federal funding and changes in nursing graduate study.
• Leverage the Workforce Investment Act to build the long-term care workforce.
• Strengthen training and licensing standards for geriatric care.
• Enact strategies to increase wages and benefits for direct care workers.

Information

• Provide federal support for comparative effectiveness research.
• Develop a federal strategy for the dissemination and application of comparative effectiveness research.

Organization of Health Care Delivery

• Promote a flexible payment reform strategy in public programs to encourage the formation of more organized groups.
• Engage providers in the development of public reporting methods to increase transparency for consumers and provide useful feedback to providers.
• Develop a federal commission to oversee system innovations, including new organizational models, by modifying regulatory protections that were developed in the context of fee-for-service reimbursement, among other things.
• Encourage the adoption of information technologies.
• Provide government oversight of accountable care organizations to ensure basic protections to the public.

Quality of Care

Improving individual care

• Strengthen oversight in Medicare and Medicaid by supporting programs that designate, monitor, and support progress in health care facilities.
• Encourage public-private payer cooperation that will specify, enforce, and support care improvements.
• Increase funding for the Agency for Healthcare Research and Quality and expand its role in quality research and development.
• Hold hospital boards legally accountable for quality and safety improvements.
• Support no-fault malpractice demonstration projects.

Improving care across the population

• Simplify and standardize health care administration, such as codes and billing, across health care industries.
• Implement comparative effectiveness studies for treatment practices.
• Develop a national initiative to reduce preventable hospital admissions and readmissions.
• Expand hospice through support to community-based programs.

Provider Payment Incentives

Short term

• Revamp the process for updating the relative value scale used in Medicare’s physician fee schedule so that relative values more accurately reflect relative costs.
• Reduce relative values for services undergoing high rates of growth in volume.
• Adopt incentives for additional processes that improve patient care such as electronic health records.

Long term

• Promote bundled payment covering all providers for acute episodes of care and post-acute care.
• Support capitated payment for the management of chronic disease. The medical home can be seen as a first of such an initiative.
• Revise or eliminate Sustainable Growth Rates in conjunction with a major package of payment reforms.

Patient Activation

• Fund research to identify key elements of effective self-management programs.
• Support self-management through benefit design such as using financial incentives for patients to encourage the use of care that is proven to be effective and discourage care that has less evidence for efficacy.
• Support self-management through provider incentives, linking payments to increases in patient activation.
• Ensure that information technology enables self-management by improving patients’ access to personal health information.
• Promote provider support for patient-centered care.

Population Health

• Set national goals of improved health performance, both absolutely and in comparison with other developed nations, and fix organizational responsi¬bility and authority for achieving those goals.
• Enact comprehensive tobacco control policies, including a federal smoke-free policy, increased tobacco taxes, warning labels, countermarketing strate¬gies, and smoking cessation efforts.
• Reduce obesity through policies such as updating nutritional standards for school lunches, expanding social marketing, eliminating “food desserts,” and promoting physical activity through workplaces and schools.

Author Biographies

Robert Berenson, M.D., is a senior fellow at the Urban Institute. From 1998 to 2000, he was in charge of Medicare payment policy and managed care contracting at the Centers for Medicare and Medicaid Services. He is clini- cal professor at the George Washington University School of Medicine and an adjunct professor at the Fuqua School of Business at Duke University.

Donald Berwick, M.D., M.P.P., F.R.C.P., is the president and CEO of the non- profit Institute for Healthcare Improvement. An elected member of the Insti- tute of Medicine, he served two terms on the Institute of Medicine’s gov- erning council. He also served on President Clinton’s Advisory Commis- sion on Consumer Protection and Quality in the Healthcare Industry. He is clinical professor of pediatrics and health care policy at the Harvard Medi- cal School, and professor of health policy and management at the Harvard School of Public Health.

David Blumenthal, M.D., M.P.P., is director of the Institute for Health Policy and a physician at the Massachusetts General Hospital/Partners HealthCare System in Boston, Massachusetts. He is also Samuel O. Thier Professor of Medicine and Professor of Health Care Policy at Harvard Medical School.

Chiquita Brooks-LaSure, M.P.P., is currently professional staff on the House Ways & Means Committee. Prior to joining the committee, she was a director at Avalere Health, LLC. From 1999 to 2003, she worked in the health division of the White House Office of Management and Budget.

Karen Davenport, M.P.A., is the director of health policy at the Center for American Progress. Previously, she served as a senior program officer at the Robert Wood Johnson Foundation, as a legislative assistant for Senator Bob Kerrey (D-NE), and as a Medicaid analyst with the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services).

Paul B. Ginsburg, Ph.D., is the president of the Center for Studying Health System Change and has been named six times to Modern Healthcare’s list of the 100 most powerful persons in health care. Previously he served as the founding executive director of the Physician Payment Review Commission (now the Medicare Payment Advisory Commission), a senior economist at RAND, and as deputy assistant director at the Congressional Budget Office.

Katherine Hayes, J.D., is the vice president of health policy at Jennings Policy Strategies, Inc. Prior to joining JPS, Inc., she served as health counsel to Senator Evan Bayh (D-IN) and legislative assistant to Senator John Chafee (R-RI). Her private sector experience includes serving as policy director to Ascension Health and legal practice as an attorney with the Washington-based law firm Hogan & Hartson.

Judith Hibbard, Dr.P.H., M.P.H., is a professor of health policy at the University of Oregon. Her research is supported by the Robert Wood Johnson Foundation, the Agency for Health Care Research and Quality, the Health Care Industry Forum, and the AARP Public Policy Institute. She has served on several advisory panels and commissions, including the National Advisory Counsel for AHRQ, the National Health Care Quality Forum, United Health Group Advisory Panel, and the National Advisory Council for the Robert Wood Johnson Foundation.

Dora L. Hughes, M.D., M.P.H., serves as health policy advisor to Senator Barack Obama (D-IL). She previously served as deputy director for health for Senator Edward M. Kennedy (D-MA). Prior to working on Capitol Hill, she served as senior program officer at The Commonwealth Fund.

Jeanne M. Lambrew, Ph.D., is a senior fellow at the Center for American Progress and an associate professor of public affairs at the Lyndon B. Johnson School of Public Affairs at the University of Texas. From 1997 to 2000, she worked on health policy at the White House as the program associate director for health at the Office of Management and Budget and as the senior health analyst at the National Economic Council. She was the White House lead on drafting and implementing the Children’s Health Insurance Program, and helped develop the president’s Medicare reform plan and initiative on long-term care.

Meredith King Ledford, M.P.P., is an independent health policy consultant. Previously, she served as the health policy research analyst at the Center for American Progress and as the Medicaid research analyst at the Health Assistance Partnership of Families USA.

Thomas H. Lee, M.D., MSc., is an internist and cardiologist, and is network president for Partners Healthcare System and chief executive officer for Partners Community HealthCare, Inc. He is a professor of medicine at Harvard Medical School and a professor of health policy and management at Harvard School of Public Health.

John D. Podesta, J.D., is the president and chief executive officer of the Center for American Progress. He served as chief of staff to President William J. Clinton from October 1998 until January 2001. He also served from 1997 to 1998 as both an assistant to the president and deputy chief of staff. Earlier, from January 1993 to 1995, he was assistant to the president, staff secretary, and a senior policy adviser on government information, privacy, telecommunications security, and regulatory policy. He is currently a visiting professor of law on the faculty of the Georgetown University Law Center.

David J. Rothman, Ph.D., is the director of the Institute on Medicine as a Profession at Columbia University. He is the Bernard Schoenberg Professor of Social Medicine and Professor of History and serves as the direc- tor of the Center for the Study of Science and Medicine at the College of Physicians and Surgeons at Columbia. He specializes in social history and the history of medicine.

Steven A. Schroeder, M.D., is Distinguished Professor of Health and Health Care at the University of California, San Francisco, where he also serves as the director of the Smoking Cessation Leadership Center at UCSF. Previously, he served as the president and CEO of the Robert Wood Johnson Foundation from 1990 to 2002.

Acknowledgments

The Center for American Progress and the Institute on Medicine as a Profession would like to thank all of the authors who contributed their personal time and commitment to the project and the development of this book. We would also like to thank the project’s advisory board, consisting of Sabrina Collette, Sen. Tom Daschle, Gerry Shea, Glenn Steele, and Jim Tallon, who provided guidance, perspective, and feedback throughout the project and throughout the production of the book. Special thanks go to Meredith King Ledford, who both contributed to the substance and managed this project with skill and dedication.