THE LEARNING HEALTH SYSTEM SERIES

THE HEALTHCARE IMPERATIVE

Lowering Costs and Improving Outcomes

Workshop Series Summary

Pierre L. Yong, Robert S. Saunders, and LeighAnne Olsen, Editors

ROUNDTABLE ON VALUE & SCIENCE-DRIVEN HEALTH CARE

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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THE LEARNING HEALTH SYSTEM SERIES ROUNDTABLE ON VALUE & SCIENCE-DRIVEN HEALTH CARE THE HEALTHCARE IMPERATIVE Lowering Costs and Improving Outcomes Workshop Series Summary Pierre L. Yong, Robert S. Saunders, and LeighAnne Olsen, Editors

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. This project was supported by the Peter G. Peterson Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-14433-9 International Standard Book Number-10: 0-309-14433-7 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap. edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent ad- opted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2010. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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ROUNDTABLE ON VALUE & SCIENCE-DRIVEN HEALTH CARE1 Denis A. Cortese (Chair), Emeritus President and Chief Executive Officer, Mayo Clinic; Foundation Professor, ASU Donald Berwick, Administrator, Centers for Medicare & Medicaid Services (ex officio) David Blumenthal, National Coordinator, Office of the National Coordinator for Health IT (ex officio) Bruce G. Bodaken, Chairman, President, and Chief Executive Officer, Blue Shield of California David R. Brennan, Chief Executive Officer, AstraZeneca PLC Paul Chew, Chief Science Officer and CMO, sanofi-aventis U.S., Inc. Carolyn M. Clancy, Director, Agency for Healthcare Research and Quality (ex officio) Michael J. Critelli, Former Executive Chairman, Pitney Bowes, Inc. Helen Darling, President, National Business Group on Health Thomas R. Frieden, Director, Centers for Disease Control and Prevention (designee: Chesley Richards) (ex officio) Gary L. Gottlieb, President and CEO, Partners HealthCare System James A. Guest, President, Consumers Union George C. Halvorson, Chairman and Chief Executive Officer, Kaiser Permanente Margaret A. Hamburg, Commissioner, Food and Drug Administration (ex officio) Carmen Hooker Odom, President, Milbank Memorial Fund Ardis Hoven, Professor of Medicine, University of Kentucky; Chair-elect, American Medical Association Brent James, Chief Quality Officer and Executive Director, Institute for Health Care Delivery Research, Intermountain Healthcare Michael M. E. Johns, Chancellor, Emory University Craig Jones, Director, Vermont Blueprint for Health Cato T. Laurencin, Vice President for Health Affairs, Dean of the School of Medicine, University of Connecticut Stephen P. MacMillan, President and Chief Executive Officer, Stryker Mark B. McClellan, Director, Engelberg Center for Healthcare Reform, The Brookings Institution Sheri S. McCoy, Worldwide Chairman, Johnson & Johnson Pharmaceuticals Group Elizabeth G. Nabel, President, Brigham and Women’s Hospital 1 Formerly the Roundtable on Evidence-Based Medicine. IOM forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. v

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Mary D. Naylor, Professor and Director of Center for Transitions in Health, University of Pennsylvania Peter Neupert, Corporate Vice President, Health Solutions Group, Microsoft Corporation Nancy H. Nielsen, Past President, American Medical Association William D. Novelli, Former CEO, AARP; Professor, Georgetown University Jonathan B. Perlin, Chief Medical Officer and President, Clinical Services, HCA, Inc. Robert A. Petzel, Under Secretary, Veterans Health Administration (ex officio) Richard Platt, Professor and Chair, Harvard Medical School and Harvard Pilgrim Health Care John C. Rother, Group Executive Officer, AARP John W. Rowe, Professor, Mailman School of Public Health, Columbia University Susan Shurin, Acting Director, National Heart, Lung, and Blood Institute (ex officio) Mark D. Smith, President and CEO, California HealthCare Foundation George P. Taylor, Assistant Secretary for Health Affairs (Acting), Department of Defense (designee: Michael Dinneen) (ex officio) Reed D. Tuckson, Executive VP and Chief of Medical Affairs, UnitedHealth Group Frances M. Visco, President, National Breast Cancer Coalition Workshop Planning Committee Arnold Milstein (Chair), Pacific Business Group on Health Kathleen Buto, Johnson & Johnson Robert S. Galvin, Global Healthcare/General Electric Paul B. Ginsburg, Center for Studying Health System Change Eric Jensen, McKinsey Global Institute James Mathews, Medicare Payment Advisory Commission Nancy H. Nielsen, American Medical Association Steven D. Pearson, Institute for Clinical and Economic Review Gail Shearer, Consumers Union Reed V. Tuckson, UnitedHealth Group Roundtable Staff Christie Bell, Financial Associate Patrick Burke, Financial Associate (through December 2009) Jane Fredell, Program Assistant (through September 2009) China Dickerson, Program Assistant (through November 2009) vi

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Chanda Ijames, Program Assistant (through December 2009) J. Michael McGinnis, Senior Scholar and Executive Director Claudia Grossmann, Program Officer LeighAnne Olsen, Program Officer (through June 2010) Brian Powers, Program Assistant Robert Saunders, Program Officer Pierre L. Yong, Program Officer (through May 2010) Kate Vasconi, Senior Program Assistant Catherine Zweig, Senior Program Assistant (through June 2010) vii

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this report: Helen Darling, National Business Group on Health Robert S. Mecklenberg, Virginia Mason Medical Center Sheila Smith, Office of the Actuary Sean Tunis, Center for Medical Technology Policy Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by Floyd Bloom. Appointed by the National Research Council and the Insti- tute of Medicine, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Re- sponsibility for the final content of this report rests entirely with the editors and the institution. ix

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Institute of Medicine Roundtable on Value & Science-Driven Health Care1 Charter and Vision Statement The Institute of Medicine’s Roundtable on Value & Science-Driven Health Care has been convened to help transform the way evidence on clinical effec- tiveness is generated and used to improve health and health care. Participants have set a goal that, by the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information, and will reflect the best available evidence. Roundtable members will work with their colleagues to identify the issues not being adequately addressed, the nature of the barriers and possible solutions, and the priorities for action, and will marshal the resources of the sectors represented on the Roundtable to work for sustained public-private cooperation for change. ****************************************** The Institute of Medicine’s Roundtable on Value & Science-Driven Health Care has been convened to help transform the way evidence on clinical effec- tiveness is generated and used to improve health and health care. We seek the development of a learning health system that is designed to generate and apply the best evidence for the collaborative healthcare choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care, and to ensure innovation, quality, safety, and value in health care. Vision: Our vision is for a healthcare system that draws on the best evi- dence to provide the care most appropriate to each patient, emphasizes preven- tion and health promotion, delivers the most value, adds to learning throughout the delivery of care, and leads to improvements in the nation’s health. Goal: By the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information, and will reflect the best available evidence. We feel that this presents a tangible focus for progress toward our vision, that Americans ought to expect at least this level of perfor- mance, that it should be feasible with existing resources and emerging tools, and that measures can be developed to track and stimulate progress. Context: As unprecedented developments in the diagnosis, treatment, and long-term management of disease bring Americans closer than ever to the promise of personalized health care, we are faced with similarly unprecedented challenges to identify and deliver the care most appropriate for individual needs and conditions. Care that is important is often not delivered. Care that is delivered is often not important. In part, this is due to our failure to apply the evidence we have about the medical care that is most effective—a failure related to shortfalls in provider knowledge and accountability, inadequate care coordination and support, lack of insurance, poorly aligned payment incen- 1 Formerly the Roundtable on Evidence-Based Medicine. xi

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xiv FOREWORD This summary highlights the presentations and discussions from these workshops, delving into the major causes of excess spending, waste, and inefficiency in health care; considering the strategies that might reduce per capita health spending in the United States while improving health out- comes and preserving innovation; and exploring the policy options that would facilitate those strategies. The ideas and observations throughout this volume are offered in the belief that health reform, now and in the future, will benefit from identifying actionable options to lower healthcare costs in ways that maximize value. I would like to extend my personal thanks especially to the Peter G. Peterson Foundation and its President, David Walker, to the Planning Com- mittee assembled for the series, to the Roundtable membership for their continued leadership and commitment to advancing health care in this na- tion, and to the Roundtable staff for their contributions in coordinating and supporting the meeting series and ongoing Roundtable activities. Harvey V. Fineberg, M.D., Ph.D. President, Institute of Medicine

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Preface Stimulated by the challenges facing our nation as healthcare expendi- tures continue to soar and threaten our fiscal future, the four-part work- shop series The Healthcare Imperative: Lowering Costs and Improving Outcomes, supported by the Peter G. Peterson Foundation, explored in detail the sources and implications of waste and excess cost in health care, as well as the strategies and policies necessary to address the issues. This volume summarizes the workshops, which were convened in May, July, Sep- tember, and December of 2009 by the Institute of Medicine (IOM) Round- table on Value & Science-Driven Health Care (formerly the Roundtable on Evidence-Based Medicine), as part of its Learning Health System workshop series. These meetings offered a forum for the broad spectrum of stake- holders in health to discuss the range of issues pertinent to reducing health spending without compromising health status, quality of care, or valued innovation. The discussion summary and its related presentations reflect the contributions of experts from multiple sectors involved in leadership, policy, practice, and innovation on behalf of better value in health care. Guided by its membership, the vision of the IOM Roundtable on Value & Science-Driven Health Care is to catalyze the development of a learning health system—a system in which the processes and systems utilized by the healthcare system enable both the natural delivery of best care practices and the real-time generation and application of new evidence. With the support of senior leadership from the country’s key healthcare sectors, the Roundtable has furthered its vision through collaborative initiatives, including public workshops and published proceedings. This workshop series emerged from prior work of the Roundtable on value in health care, xv

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xvi PREFACE as well as the ongoing dialogue on healthcare reform, and provided a forum for stakeholders to discuss their perspectives and to identify ideas and areas for further consideration. The contributions of the workshop discussions to better understanding have been conceptual, quantitative, and qualitative. Conceptually, the ap- proach fashioned by the Planning Committee grouped the sources of excess costs in health care into six domains: unnecessary services (volume), ser- vices delivered inefficiently, prices that are too high, excessive administra- tive costs, missed prevention opportunities, and fraud. Except for the last, the sessions organized by the Committee for the first workshop reviewed these domains in detail, and, while much work remains, the workshop presentations have offered a substantially enhanced understanding of the nature and size of the problems in each of those domains. Two things are clear: (1) each is an important contributor to excessive healthcare costs, and (2) the amount of excessive costs incurred from each is tremendous. In discussions about potential cost control strategies and policy op- tions, key levers for change were identified and considered in the second and third workshops, as vehicles for initiatives of particular policy relevance, including payment transformation, governance streamlining, transparency, knowledge development, care system redesign, and community health ca- pacity. The nature, barriers, and potential impact of the various measures were extensively explored. At the request of the Planning Committee, a fourth workshop was scheduled to focus solely on the Series’ motivating proposition: reducing healthcare costs by 10 percent within 10 years, with- out compromising health outcomes or valued innovation. Throughout the progression of the meetings, a number of opportunities and challenges were also identified around which the engagement of stake- holders such as those represented on the Roundtable, might be especially important and facilitative. These issues will be explored through future workshops, commissioned papers, collaborative activities, and public com- munication efforts. We are especially indebted to the members of the Planning Commit- tee, which crafted this unusually productive and path-breaking discussion series. The members of this stellar group were: Arnold Milstein (Pacific Business Group on Health, Committee Chair), Kathleen Buto (Johnson & Johnson), Robert S. Galvin (Global Healthcare/General Electric), Paul B. Ginsburg (Center for Studying Health System Change), Eric Jensen (McKinsey Global Institute), James Mathews (Medicare Payment Advisory Commission), Nancy H. Nielsen (American Medical Association), Steven D. Pearson (Institute for Clinical and Economic Review), Gail Shearer (Consumers Union), and Reed V. Tuckson (UnitedHealth Group). Multiple other individuals and organizations donated their valuable time toward the development of this publication. We naturally also ac-

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xvii PREFACE knowledge and offer strong appreciation for the contributors to this volume, for the care and thought that went into their analyses and presenta- tions, for the ideas and observations they shared at the workshops, and for their contributions to this summary publication. In this respect, we should underscore that this volume contains a collection of individually authored papers and intends to convey only the views and beliefs of those participat- ing in the workshops, not the express opinions of the Roundtable on Value & Science-Driven Health Care, its members, its sponsors, or the Institute of Medicine. A number of Roundtable staff played instrumental roles in coordinat- ing the workshops and translating the workshop proceedings into this summary, including Pierre L. Yong (the staff officer with primary respon- sibility), Catherine Zweig, LeighAnne Olsen, Kate Vasconi, Jane Fredell, China Dickerson, Chanda Ijames, Patrick Burke, Christie Bell, and Ruth Strommen. Franklin A. Cruz also contributed substantially to publication development. We would also like to thank Vilija Teel, Jordan Wyndelts, Michele de la Menardiere, and Jackie Turner for helping to coordinate the various aspects of review, production, and publication. Clearly, successfully addressing the challenges of lowering healthcare expenditures while preserving outcomes and innovation will require signifi- cant effort and collaboration. We believe the dialogue emerging from The Healthcare Imperative begins to define the opportunities and options for successfully tackling this challenge, and look forward to continued learning from its insights. Denis A. Cortese Chair, Roundtable on Value & Science-Driven Health Care J. Michael McGinnis Executive Director, Roundtable on Value & Science- Driven Health Care Arnold Milstein Planning Committee Chair

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Contents Synopsis and Overview 1 SECTION I: EXCESSIVE HEALTHCARE COSTS 1 THE HEALTHCARE IMPERATIVE 69 Promoting Efficiency and Reducing Disparities in Health Care, 72 Peter R. Orszag Why Americans Spend More for Health Care, 76 Eric Jensen and Lenny Mendonca 2 UNNECESSARY SERVICES 85 Saving Money (and Lives), 86 Amitabh Chandra, Jonathan S. Skinner, and Douglas O. Staiger Regional Insights and U.S. Health Care Savings, 95 Elliott S. Fisher and Kristen K. Bronner Opportunities to Reduce Unwarranted Care Differences, 101 David Wennberg 3 INEFFICIENTLY DELIVERED SERVICES 109 Costs of Errors and Inefficiency in Hospitals, 111 Ashish Jha Costs from Inefficient Use of Caregivers, 116 Robert S. Mecklenburg and Gary S. Kaplan xix

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xx CONTENTS Costs from Physician Office Inefficiencies, 125 William F. Jessee Low-Cost Hospitals with High-Quality Scores, 129 Arnold Milstein Costs of Uncoordinated Care, 131 Mary Kay Owens 4 ExCESS AdmInIStrAtIvE COStS 141 Excess Billing and Insurance-related Administrative Costs, 142 James G. Kahn What does It Cost Physician Practices to Interact with Payers?, 151 Lawrence P. Casalino, Sean Nicholson, David N. Gans, Terry Hammons, Dante Morra, and Wendy Levinson Cost Savings from Simplifying the Billing Process, 159 James L. Heffernan, Bonnie B. Blanchfield, Brad Osgood, Rosemary Sheehan, and Gregg S. Meyer Excess Health Insurance Administrative Expenses, 166 Andrew L. Naugle 5 PrICES tHAt ArE tOO HIgH 175 Price Implications of Hospital Consolidation, 177 Cory S. Capps Prescription drug Prices, 187 Jack Hoadley durable medical Equipment Prices, 197 Thomas J. Hoerger market Pricing and the medicare Program, 202 Mark E. Wynn medical device Prices, 209 Jeffrey C. Lerner 6 mISSEd PrEvEntIOn OPPOrtUnItIES 219 the Price Paid for not Preventing diseases, 220 Steven H. Woolf Cost Savings from Primary and Secondary Prevention, 225 Thomas J. Flottemesch, Michael V. Maciosek, Nichol M. Edwards, Leif I. Solberg, and Ashley B. Coffield tertiary Prevention and treatment Costs, 232 Michael P. Pignone

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xxi CONTENTS SECTION II: STRATEGIES THAT WORK 7 StrAtEgIES tHAt WOrk 241 Strategies that Work and How to get there, 245 Glenn Steele, Jr. International Success at Cost Containment, 251 Gerard F. Anderson 8 knOWLEdgE EnHAnCEmEnt 257 Successes with Cost and Quality, 259 Lucy A. Savitz the value of Electronic Health records with decision Support, 265 Rainu Kaushal and Lisa M. Kern Comparative Effectiveness research, 270 Carolyn M. Clancy Enhancing Clinical data as a knowledge Utility, 273 Peter K. Smith 9 CArE CULtUrE And SyStEm rEdESIgn 281 Community-Engaged models of team Care, 283 Michelle J. Lyn, Mina Silberberg, and J. Lloyd Michener Using Production System methods in medical Practice: Improving medical Costs and Outcomes, 287 Kim R. Pittenger managing variability in Healthcare delivery, 294 Eugene Litvak, Sandeep Green Vaswani, Michael C. Long, and Brad Prenney Cost Savings from managing High-risk Patients, 301 Timothy G. Ferris, Eric Weil, Gregg S. Meyer, Mary Neagle, James L. Heffernan, and David F. Torchiana Health Information Exchange and Care Efficiency, 310 Ashish Jha Antitrust Policy in Health Care, 314 Roger Feldman reducing Service Capacity: Evidence and Policy Options, 319 Frank A. Sloan malpractice reform and Healthcare Costs, 324 Randall R. Bovbjerg 10 trAnSPArEnCy Of COSt And PErfOrmAnCE 335 transparency in the Cost of Care, 337 John Santa

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xxii CONTENTS transparency in Comparative value of treatment Options, 340 G. Scott Gazelle Provider Price and Quality transparency, 344 Paul B. Ginsburg transparency to Improve the value of Hospital Care, 347 Peter K. Lindenauer Health Plan transparency, 352 Margaret E. O’Kane 11 PAymEnt And PAyEr-BASEd StrAtEgIES 359 value-Based Payments, Outcomes, and Costs, 361 Harold D. Miller Bundled and fee-for-Episode Payments: An Example, 370 Francois de Brantes, Amita Rastogi, Alice Gosfield, Doug Emery, and Edison Machado Effective Health Insurance Exchanges: An Example, 376 David R. Riemer value-Based Insurance designs and Healthcare Spending, 380 Niteesh K. Choudhry tiered-Provider networks and value, 386 Lisa Carrara Simplifying Administrative Complexity, 390 Robin J. Thomashauer technology and Simplifying Healthcare Administration, 397 David S. Wichmann 12 COmmUnIty-BASEd And trAnSItIOnAL CArE 407 Community Health teams: Outcomes and Costs, 408 Kenneth E. Thorpe and Lydia L. Ogden Palliative Care, Quality and Costs, 415 Diane E. Meier, Jessica Dietrich, R. Sean Morrison, and Lynn Spragens Community Prevention and Healthcare Costs, 420 Jeffrey Levi 13 EntrEPrEnEUrIAL StrAtEgIES 433 decentralizing Healthcare delivery, 435 Jason Hwang retail Clinics and Healthcare Costs, 438 N. Marcus Thygeson Care Coordination and Home telehealth (CCHt), 443 Adam Darkins

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xxiii CONTENTS SECTION III: THE POLICY AGENDA 14 tHE POLICy AgEndA 455 getting to High-Performance, 456 Karen Davis CBO Scoring: methods and Implications, 465 Joseph R. Antos 15 PAymEntS fOr vALUE OvEr vOLUmE 473 Bundled Payments: A Private Payer Perspective, 474 John M. Bertko medicare and Bundled Payments, 478 Armen H. Thoumaian, Linda M. Magno, and Cynthia K. Mason Bundled Payment: Physician Engagement Issues, 482 George J. Isham Patient Perspective and Payment reform, 489 Nancy Davenport-Ennis 16 mEdICALLy COmPLEx PAtIEntS 493 Payment Policies and medically Complex Patients, 495 Arnold Milstein Palliative Care, Access, Quality, and Costs, 498 R. Sean Morrison, Diane E. Meier, and Melissa Carlson Payment and Better Care of Complex Patients, 504 Ronald A. Paulus, Jonathan Darer, and Walter F. Stewart Care of Patients with multiple Chronic Conditions, 509 Anand K. Parekh 17 dELIvEry SyStEm IntEgrAtIOn 517 Profile of System fragmentation, 519 John Toussaint Payments to Promote delivery System Integration, 520 Mark E. Miller Payment reform to Promote Integration and value, 525 Harold S. Luft Health Information technology to Promote Integration, 529 Andrew M. Wiesenthal 18 dELIvEry SyStEm EffICIEnCy 535 Better Use of Healthcare Professionals, 536 Mary D. Naylor

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xxiv CONTENTS transparency and Informed Choice, 542 Steven J. Spear 19 AdmInIStrAtIvE SImPLIfICAtIOn 547 Administrative Simplification and Payer Harmonization, 548 Lewis G. Sandy Payer Harmonization on the Provider Perspective, 552 Linda L. Kloss Policies targeting Payer Harmonization, 556 Harry Reynolds 20 COnSUmEr-dIrECtEd POLICIES 569 Consumer views of Higher-value Care, 570 Jennifer Sweeney Insurers, Consumers, and Higher-value Care, 574 Dick Salmon and Jeffrey Kang Policies Shaping Consumer Preferences on value, 577 Dolores L. Mitchell SECTION IV: GETTING TO 10 PERCENT 21 tAkIng StOCk: nUmBErS And POLICIES 585 A Look at the numbers, 585 J. Michael McGinnis 22 gEttIng tO 10 PErCEnt: OPPOrtUnItIES And rEQUIrEmEntS 599 23 COmmOn tHEmES And nExt StEPS 619 APPENDIxES* A Workshop discussion Background Paper 635 B Workshop Agendas 755 C Planning Committee Biographies 773 d Speaker Biographies 779 *Appendixes A-d are not printed in this book. they are available online at http://www.nap. edu/catalog.php?record_id=12750.