18
Delivery System Efficiency

INTRODUCTION

While fragmentation of the delivery system has been identified as a driver of inefficient and ineffective care (Stange, 2009; Wiggins, 2008), inefficiencies in the delivery of care have also been highlighted as a source of wasted opportunity. Efficiencies could be maximized through the elimination of non-value added activities (Klein and McCarthy, 2009; Toussaint, 2009) or through the expanded use of non-physician caregivers (Eibner et al., 2009; Roblin et al., 2004). From using market forces to effect change by empowering consumers to make informed choices to redefining who provides health care, the presenters in this session discuss innovations to improve delivery system efficiency.

Mary D. Naylor from the University of Pennsylvania asserts that enhancing the effectiveness and efficiency of the U.S. healthcare system is dependent upon maximizing the contributions of non-physician healthcare professionals. Naylor relates that licensed independent practitioners (LIPs) can be used more robustly to deliver health care at lower cost. Furthermore, not only can LIPs deliver existing services more cost efficiently, they can also enhance current services by providing more thorough follow-up and case management. Greater use of LIPs, which include advance practice registered nurses, allied health professionals such as physical therapists and occupational therapists, pharmacists, and clinical social workers, can translate into significant efficiencies. Naylor also provides insight into existing barriers to expanding the use of LIPs and offers several policy recommendations to



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18 Delivery System Efficiency INTRODUCTION While fragmentation of the delivery system has been identified as a driver of inefficient and ineffective care (Stange, 2009; Wiggins, 2008), in- efficiencies in the delivery of care have also been highlighted as a source of wasted opportunity. Efficiencies could be maximized through the elimina- tion of non-value added activities (Klein and McCarthy, 2009; Toussaint, 2009) or through the expanded use of non-physician caregivers (Eibner et al., 2009; Roblin et al., 2004). From using market forces to effect change by empowering consumers to make informed choices to redefining who provides health care, the presenters in this session discuss innovations to improve delivery system efficiency. Mary D. Naylor from the University of Pennsylvania asserts that en- hancing the effectiveness and efficiency of the U.S. healthcare system is dependent upon maximizing the contributions of non-physician healthcare professionals. Naylor relates that licensed independent practitioners (LIPs) can be used more robustly to deliver health care at lower cost. Furthermore, not only can LIPs deliver existing services more cost efficiently, they can also enhance current services by providing more thorough follow-up and case management. Greater use of LIPs, which include advance practice registered nurses, allied health professionals such as physical therapists and occupa- tional therapists, pharmacists, and clinical social workers, can translate into significant efficiencies. Naylor also provides insight into existing barriers to expanding the use of LIPs and offers several policy recommendations to 

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 THE HEALTHCARE IMPERATIVE facilitate their contributions, including revising state “scope-of-practice” laws and payment reform that emphasizes the team as the payment unit. Steven J. Spear of the Massachusetts Institute of Technology suggests that large opportunities currently exist to advance quality, access, and cost simultaneously by focusing on care delivery. Despite significant disparities between the quality of providers, patients and payers cannot distinguish which providers provide the highest-quality care at affordable cost. By focusing on empowering patients and payers with this information, he explains, transparency has the ability to promote efficiency within the healthcare system. BETTER USE OF HEALTHCARE PROFESSIONALS Mary D. Naylor, Ph.D., R.N. University of Pennsylvania School of Nursing Over the last decade, there has been a growing awareness of the lags in healthcare quality in the United States. Today’s system is plagued by suboptimal, uneven, and error-prone care. While early reports published by the Institute of Medicine (IOM) (IOM, 2001; Kohn et al., 2000) placed a spotlight on healthcare quality, more recent reports (AHRQ, 2007, 2008; The Commonwealth Fund Commission on a High Performance Health System, 2008; Joint Commission, 2008) have generated new knowledge in this area and confirmed what we have suspected for years—that tremendous dysfunction, chaos, and underperformance exist in every setting of health care and for all patients. These quality lags are particularly alarming when taking our nation’s healthcare investment into account. This year, the United States will spend more than $2.5 trillion on health care, an estimated 17 percent of the gross domestic product (GDP). By 2017, U.S. healthcare spending is expected to nearly double from 2007’s projected level, reaching $4.3 trillion and con- suming 19.5 percent of the nation’s GDP (Anonymous, 2008). While U.S. spending surpasses that of other developed countries, outcomes lag for key indicators such as preterm births, infant mortality, and life expectancy. To interrupt these trends, national leaders are exploring solutions that both improve outcomes and lower costs. This paper is based on the under- lying assumption that “the needs and preferences of every patient should be met by the healthcare professional with the most appropriate skills and training to provide the necessary care” (American College of Physicians, 2009). It summarizes the evidence base that demonstrates cost savings and performance improvements by maximizing the existing healthcare work- force, including licensed independent practitioners and physician assistants (PAs). Four key questions have been addressed:

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 DELIVERY SYSTEM EFFICIENCY • What is known about the contributions of healthcare professionals (other than physicians) in achieving high-value health care? • What evidence-based models serve as exemplars? • What barriers to optimizing the contributions of licensed indepen- dent practitioners have been identified? • What policy options will maximize their contributions? Licensed Independent Practitioners A licensed independent practitioner is “any individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual’s license and consistent with individually granted clinical privileges” (Joint Commission, 2009). These practitioners operate under their own licenses and their respec- tive scopes of practice in the delivery of healthcare services. The popula- tion of LIPs is diverse and encompasses advance practice registered nurses (APRNs)—including nurse practitioners (NPs), clinical nurse specialists, nurse midwives, and nurse anesthetists—and allied health professionals such as physical and occupational therapists, pharmacists, and clinical social workers. LIPs practice in a variety of settings, including health cen- ters and clinics, primary care practices, hospitals, and community-based services. It should be noted that APRNs are licensed in many states as LIPs, while physician assistants operate under the physician’s license. Contribution of LIPs and PAs to High-Value Health Care A substantial, consistent, and mature evidence base reveals that LIPs and PAs deliver high-value health care. This evidence base is richest and strongest in demonstrating the NP- and PA-value equation. A number of rigorous studies dating back to 1981 and including randomized controlled clinical trials (RCTs), systematic reviews, and meta-analyses demonstrate the equivalence and cost effectiveness of NPs and PAs. Among the first to report this phenomenon was the Office of Technology Assessment (OTA), which described the value of NPs in its 1981 report The Cost and Effective- ness of Nurse Practitioners. More recently, these findings have been con- firmed. A systematic review and meta analysis conducted by Horrocks and colleauges, for example, found that when compared to physician practices, NP practices produce equivalent or better patient outcomes (e.g., health status, adherence, symptom relief), care processes (e.g., care management), and patient satisfaction (Horrocks et al., 2002). Multiple studies that have compared NP or physician-NP teams to physician-only practices find that NP or physician-NP teams decrease both utilization and healthcare costs (American Academy of Nurse Practitioners, 2007). A review of more than

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 THE HEALTHCARE IMPERATIVE 27,000 individual titles and 30 outcomes by Newhouse and colleagues is expected to provide further evidence supporting the contribution of NPs to value (Tri-Council of Nursing, 2008). The potential policy impacts of these findings are not inconsequen- tial. On behalf of the Commonwealth of Massachusetts, for example, the RAND Corporation assessed cost containment strategies and options under the state’s Chapter 58 of the Acts of 2006, which was aimed at expanding healthcare coverage. In its evaluation of various strategies, RAND found that over a 10-year period (2010-2020), the cost savings associated with increased use of NPs and PAs would be between $4 billion and $8 billion. This strategy was among a handful that both produced cost savings at the lower-range estimates and produced savings in the first year. The literature beyond NPs and PAs is less extensive but consistent. Stud- ies examining the value equation among nurse midwives, for example, have found similar achievements in both cost and quality. As one example, a 2008 Cochrane Review (Hatem et al., 2008) found that compared to obstetricians, nurse midwives are less likely to use some interventions (e.g., regional anes- thesia, episiotomies, and instrumental deliveries). This review also confirmed improved outcomes among those served by nurse midwives (e.g., increased spontaneous vaginal births, reduced lengths of stay for infants, and lower costs). Taken together, the evidence portrays a workforce that is well posi- tioned to deliver high-value health care. Specific examples of evidence-based models that achieve high value are summarized in Table 18-1. Barriers Limiting Appropriate Use of All Professionals Despite the evidence base and the existence of real-world models, there are barriers that prevent LIPs and PAs from practicing to their full capaci- ties. These can be characterized as both internal and external. Internal Barriers Despite the size and capabilities of this workforce, the roles of LIPs and PAs are typically misunderstood and have not been conveyed to the public in terms that enables patients and family caregivers to understand defined roles and responsibilities. Without an appreciation of the potential of this workforce, there is little public stimulus to invest in or facilitate LIP and PA practice. Additionally, performance measures of clinical and economic outcomes that relate to LIP and PA care generally do not exist, and those that do exist are not routinely collected or reported. This results in a lack of transpar- ency regarding the value of these practitioners among stakeholders and underlying questions regarding their relative contributions. In the absence

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9 DELIVERY SYSTEM EFFICIENCY TABLE 18-1 High-Value Models High-Value Model Advancing Better Transitional Care Living for Elders Pharmacist Intervention Characteristic Model (TCM) (ABLE) (unnamed) Aim Interrupt cycles of Reduce functional Improve adherence to repeated, unnecessary difficulties, fear of prescription medication hospitalizations among falling, and home therapy among patients chronically ill elders hazards and enhance with heart failure self-efficacy and adaptive coping in older adults with chronic conditions Model Comprehensive in- A 6-month Protocol-based description hospital planning and multicomponent home- intervention including home follow-up and based intervention a baseline medication ongoing telephone consisting of five history of all prescription support for an occupational therapy and over-the-counter average of 2 months contacts (four 90- drugs and dietary post-discharge; minute visits and one supplements taken by TCM emphasizes 20-minute telephone patients, an assessment continuity of medical contact) and one of patient medication care between physical therapy knowledge and skills, hospital and primary visit (90 minutes) patient-centered verbal care physicians, and involving home instructions and written comprehensive, modifications and materials about the holistic focus on each training in their use; medications; and patient’s needs, active instruction in strategies pharmacist-monitored engagement of patients of problem-solving, patient medication use, and their family and energy conservation, healthcare encounters, informal caregivers, safe performance, body weight, and other emphasis on early and fall recovery relevant data identification and techniques; and response to healthcare balance and muscle risks and symptoms strength training to achieve longer-term positive outcomes and avoid adverse and untoward events that lead to readmissions Reference(s) Naylor et al. (1994) Gitlin et al. (2006) Murray et al. (2007) Naylor (1999) Jutkowitz et al. (2009) Naylor et al. (2004) Setting Hospital to home Urban University-affiliated, community-based inner-city ambulatory care practice continued

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0 THE HEALTHCARE IMPERATIVE TABLE 18-1 Continued High-Value Model Advancing Better Transitional Care Living for Elders Pharmacist Intervention Characteristic Model (TCM) (ABLE) (unnamed) Population Cognitively intact Community-dwelling Low-income patients served older adults with two persons aged 70 and 50 years of age or older or more risk factors, older by modifying with heart failure including history of behavioral and recent hospitalizations, environmental multiple chronic contributors to conditions or functional decline medications, and poor self-health ratings Primary Advanced practice Physical and Registered pharmacist provider registered nurse occupational therapists of care or service Clinical Reduction in all-cause Reduced mortality Significant improvements outcomes readmission rates rates among the in medication through 1 year older adults with adherence, although post-dischargea functional difficulties effects dissipated in Improvements in Decreased deficits post-intervention physical health, in activities of 3-month follow-up functional status, daily living and period and quality of life instrumental Fewer emergency Enhancement of activities of daily department visits and patient and family living hospitalizations caregiver satisfaction Improved self- sufficiency and use of adaptive strategies Economic Reductions of nearly Decreased costs— Reduced annual direct outcomes $5,000 per patient in incremental cost- healthcare costs by total (i.e., physician, effectiveness ratio of nearly $3,000 hospital, home health) $16,000 per quality- healthcare costsa adjusted life-year (QALY) a From most recent RCT only: Naylor et al. (2004). of public performance reports, there is little to stimulate quality improve- ment or professional accountability. External Barriers The most significant external barriers are the restrictions placed on LIPs and PAs by state and federal laws and regulations, reimbursement and

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 DELIVERY SYSTEM EFFICIENCY other payment policies, and opposition from healthcare systems, profes- sional medical groups, and managed care organizations that fear competi- tion. For example, scope-of-practice laws, which define each healthcare professional’s lawful sphere of activity, are established on a state-by-state basis. This leads to a lack of uniformity across state lines. Some states (e.g., Alaska), for example, extend NPs full prescription authority and allow practice without physician supervision. Other states (e.g., Alabama) are unnecessarily restrictive and require physician oversight of almost every aspect of NP practice. Even if scope-of-practice laws were uniform and unrestrictive, current reimbursement practices serve as barriers to capitalizing on the contribu- tions of all healthcare professionals. Medicare, for example, limits NP reimbursement levels. Additionally, among most private insurers, LIPs and PAs cannot bill independently for services. Practice is seriously curtailed by these practitioners’ inability to equitably bill for the same services provided by physicians. Policy Options To overcome these barriers, healthcare stakeholders should consider the full range of policy options available. First, state scope-of-practice laws should be revised where they are unnecessarily restrictive and prevent the full use of LIPs and PAs. Federal initiatives that include and appropriately utilize these practitioners should be supported and advanced. Demonstra- tions and pilots that test specific innovations in system redesign and pay- ment reform should always include the full range of professionals who can deliver the necessary services. As an example, in considering bundled pay- ments to reduce hospital readmission, any demonstration initiated by the Centers for Medicare & Medicaid Services should enable nurse-managed health centers to receive and distribute such payments. Additionally, payment reform that emphasizes the team as the payment unit and reinforces the team’s accountability for individual and population health should be supported. Equitable payment for the same services should be the expectation reflected in payment policy, and reimbursement should in- centivize replication rather than prohibition of the spread of evidence-based models of care, such as the Transitional Care Model and other interventions profiled in Table 18-1. To address the lack of transparency and accountability that call into question the reliability of this workforce and the public’s understanding of it, performance measurement and reporting systems should be designed and implemented to address the contributions of teams and all professionals that comprise those teams. Strengthened accountability will spur ongo- ing quality improvements and cost savings among LIPs and PAs. Beyond measurement and reporting, however, a public education campaign with

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2 THE HEALTHCARE IMPERATIVE elegantly crafted messages about the roles of various healthcare profession- als would result in better-informed consumers who would likely be more supportive of the full range of practitioners and their respective areas of expertise. Finally, research aimed at assessing the value and comparative ef- fectiveness of innovative care and payment models that rely on LIPs and PAs should be vigorously pursued. While researchers should be engaged in studying these questions, government (e.g., National Institutes of Health, Agency for Healthcare Research and Quality), private philanthropies (e.g., Robert Wood Johnson Foundation, The Commonwealth Fund) should be supportive of these directions in their funding decisions. Conclusion Based on the underlying assumption that patients deserve access to healthcare professions with the most appropriate skills and training to provide the necessary care, this paper provides the evidentiary rationale, real-life examples, and policy solutions to maximize the existing LIP and PA workforce and achieve higher-value health care. TRANSPARENCY AND INFORMED CHOICE Steven J. Spear, D.B.A., M.S. Massachusetts Institute of Technology Health care’s well-documented failings include poor access, poor qual- ity, and crippling costs. Yet, for all the debate about reform, little has been proposed that will simultaneously improve quality, affordability, and access. Why? Because most proposals focus on insurer competition and coverage subsidization, whereas the area on which we need to focus is the provision of care, the place where resources get put to use well or not. Therefore, unless reform rewards the most effective and efficient providers at the expense of the worst, we will not make progress across the board. Making provider performance transparent so patients and payers can make informed choices when accessing care is necessary to accomplish this. In contrast, reforms that expand coverage without providing mechanisms for distinguishing the best providers from the pack, such as those seen in Mas- sachusetts, increase spending to improve access but do not solve the quality and cost problems. Why is this? The root causes of the access, quality, and affordability problems we have lie with the providers—hospitals, clinics, and practices. Whether great value gets created or destroyed depends on how the delivery of care is managed. There is huge variation between regions, within regions,

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 DELIVERY SYSTEM EFFICIENCY and even within institutions, with mediocre providers compromising the impact of truly great ones. Given these discrepancies, patients and payers should swarm to the good and spurn the bad, but they do not—because we do not have sufficient information to know better. Without informed choice, far too much traffic goes to those who burn a lot of resources while providing too little and too little traffic goes to those who are most effective and most efficient. (Imag- ine such blindness going into a purchase by considering buying a car, and not knowing in advance whether you will get a Lexus or a Yugo for your hard-earned money, or buying a plane ticket not knowing at which airport you will arrive.) Because those who receive care and pay for care cannot effectively determine where to get care, the overall level of care is tragically lower than it needs to be and its costs are astronomically high. How then do we move in a direction of patients making informed choices that are to their own immediate benefit and, because they bolster the best providers and diminish the worst, have societal benefit as well? First of all, there are certain events that should never happen (just as the wheels of your car or the wings of your plane should never fall off). Patients on ventilators should not get pneumonia, patients with catheters should not get urinary tract or bloodstream infections, patients should not suffer surgical site infections, patients should not fall and injure themselves, and patients should never get the wrong medication or the right medication in the wrong dose. When these things do happen, it is not because “health care is complicated” or because “every patient is different.” It is because there is a breakdown in the delivery of care. The management of care was broken. Progress is possible and attainable. Hospitals working with the Pitts- burgh Regional Healthcare Initiative (PRHI) cut the rate of bloodstream infections associated with intravenous catheters by 70 percent. Some hos- pitals cut their rates to zero. Savings were in the hundreds of lives not lost and the thousands not harmed, with extraordinary financial benefits since the cost of trying to clean up these complications runs into the tens of thousands of dollars each. The Veterans Administration (VA) eliminated a pernicious type of sur- gical site infection—again, many lives saved, even more pain and suffering avoided, and the financial impact markedly reduced. Other hospitals have eliminated other events that should never happen—patient falls, pneumo- nias while ventilated, medication errors, and the like. These hospitals have not been alone in their success. The Institute for Healthcare Improvement (IHI) sponsored a One Hundred Thousand Lives Campaign, championing practices to prevent complications such as those listed above. As a result, an estimated 122,300 patient deaths were avoided, based on 2004 levels of care.

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 THE HEALTHCARE IMPERATIVE These examples are in the acute care setting, but the possibilities are not just with in-patients. Places such as ThedaCare, Virginia Mason, and the Mayo Clinic have demonstrated remarkable success in preventive and pri- mary care, chronic illness management, and specialty care, to name a few. Therefore real, measurable change is possible, but again providers and patients need to have information about the healthcare services they are go- ing to receive. Let us know how often the system fails. Require all organiza- tions to post how well they are doing against a standard of “zero” on these never events. Next, build other measures of efficacy and efficiency from preventive and primary care to chronic, acute, intensive, and extended care. Our largest payers, both public and private, such as the Blue Cross/Blue Shield organizations, the VA, Medicare, and Medicaid, record countless interactions of patients with providers across a huge variety of conditions. They have the data to determine which therapies are most effective under which circumstances and which providers are most effective at delivering them. The data are there, but we have to apply quality standards to them. Then people can make informed choices as to whom to trust with their wealth and well-being and whom to fear. Without doubt, a caring society will ensure that the least fortunate receive health care just as we try now to make sure no one goes hungry or homeless. Also, yes, it is undoubtedly important that there be competition among insurance providers. However, if we want bona fide reform that successfully increases qual- ity and affordability (and hence access), we have to start rewarding great providers at the expense of the low performers so that the money we put into the system gets well spent, not squandered. Only then can we get health care for all in a way that is not bankrupting. REFERENCES AHRQ (Agency for Healthcare Research and Quality). 2007. National healthcare disparities report. Rockville, MD. ———. 2008. National healthcare quality report. Rockville, MD. American Academy of Nurse Practitioners. 2007. Nurse practitioner cost-effectiveness. http:// www.hospitalmedicine.org/AM/Template.cfm?Section=Reference_Material&Template=/ CM/ContentDisplay.cfm&ContentID=16740 (accessed 2009). American College of Physicians. 2009. Nurse practitioners in primary care. Philadelphia, PA. Anonymous. 2008. Health care spending expected to double by 2017, to $4.3 trillion. Hos- pitals & Health Networks 82(4):61. The Commonwealth Fund Commission on a High Performance Health System. 2008. Why not the best? Results from the national scorecard on U.S. health system performance. New York: The Commonwealth Fund. Eibner, C., P. Hussey, M. Ridgely, and E. McGlynn. 2009. Controlling health care spending in Massachusetts: An analysis of options. http://www.rand.org/pubs/technical_reports/2009/ RAND_TR733.pdf (accessed August 2009).

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 DELIVERY SYSTEM EFFICIENCY Gitlin, L. N., et al. 2006. A randomized trial of a multicomponent home intervention to reduce functional difficulties in older adults. Journal of the American Geriatrics Society 54:809-816. Hatem, M., J. Sandall, D. Devane, H. Soltani, and S. Gates. 2008. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews (4): CD004667. Horrocks, S., E. Anderson, and S. Salisbury. 2002. Systematic review of whether nurse practi- tioners working in primary care can provide equivalent care to doctors. British Medical Journal 324:819-823. IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health system for the 2st century. Washington, DC: National Academy Press. Office of Technology Assessment. 1981. The Cost and Effectiveness of Nurse Practitioners. Washington, DC: The Congress of the United States. Joint Commission. 2008. Improving America’s hospitals. Oakbrook Terrace, IL. ———. 2009. Hospital standards manual. Oakbrook Terrace, IL. Jutkowitz, E., et al. 2009. Cost-effectiveness of a functional program to increase quality of life in community-dwelling older adults. Poster session presented at the International Association of Gerontology and Geriatrics in Paris, France, July. Klein, S., and D. McCarthy. 2009. Gundersen Lutheran health system: Performance improve- ment through partnership. Case study: Organized health care delivery system. http://www. commonwealthfund.org/~/media/Files/Publications/Case%20Study/2009/Aug/1307_ McCarthy_Gundersen_Lutheran_case_study_v2.pdf (accessed 2009). Kohn, T., J. Corrigan, and K. Donaldson. 2000. To Err Is Human. Washington, DC: National Academy Press. Murray, M. D., et al. 2007. Pharmacist intervention to improve medication adherence in heart failure. Annals of Internal Medicine 146:714-725. Naylor, M. D., et al. 1994. Comprehensive discharge planning for the hospitalized elderly. Annals of Internal Medicine 120:999-1006. Naylor, M. D., et al. 1999. Comprehensive discharge planning and home follow-up of hospi- talized elders: A randomized clinical trial. Journal of the American Medical Association 281:613-620. Naylor, M. D., et al. 2004. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society 52:675-684. Roblin, D., D. Howard, E. Becker, E. Adams, and M. Roberts. 2004. Use of midlevel prac- titioners to achieve labor cost savings in the primary care practice of an MCO. Health Services Research 39(3):607-626. Stange, K. C. 2009. The problem of fragmentation and the need for integrative solutions. Annals of Family Medicine 7(2):100-103. Toussaint, J. 2009. Writing the new playbook for U.S. health care: Lessons from Wisconsin. Health Affairs (Millwood) 28(5):1343-1350. Tri-Council of Nursing. 2008. 22 national organizations join together to commission a study of the impact of advanced practice registered nurses on healthcare quality, safety, and effectiveness. American Association of Nurse Anesthetists. Illinois. Wiggins, M. S. 2008. The partnership care delivery model: An examination of the core concept and the need for a new model of care. Journal of Nursing Management 16(6):629-638.

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