The Institute for Healthcare Improvement (IHI), a not-for-profit organization with the mission to “improve health and health care worldwide,” developed the IHI Triple Aim framework to optimize healthcare performance. The three dimensions of Triple Aim are quite intuitive:
- Improve the patient experience of care
(including quality and satisfaction). - Improve the health of populations.
- Reduce the per capita cost of healthcare.
Americans are (justifiably) concerned about all three components of the Triple Aim. Yet, most of the oxygen in the room, at least in Washington, D.C., is being spent on the insurance component, which seems to ignore each of the three Triple Aim tenets. Just look at the ping-pong match happening in Congress these days regarding the repeal, replace or repair of Obamacare. Make no mistake, having health insurance allows people to seek the care they need when stricken by serious illness or injury. Without insurance, people often live sicker lives and die sooner than those with insurance.
However, the insurance card that each of us (hopefully) carries merely serves as the ticket to gaining access to the movie theatre show we know as the healthcare delivery system. Without this card, it becomes progressively more difficult to navigate through this ‘system’ and receive the best possible care. Even by having this laminated card, we may unknowingly believe that we will receive the best care available at all times – a soberly mistaken myth. The quality of care that is delivered in the U.S. is uneven and, too often, inadequate.
The three primary ‘Ps’ in healthcare relate to:
- Payers (government, employers and insurance companies)
- Providers (hospitals, physicians, etc)
- Patients (you and me)
Currently, the payers and providers work with one another to determine the best way to incentivize quality care, leaving the patient on the sidelines as a confused bystander. Whether the payment approach is fee-for-service, bundled payment, capitation or some hybrid of these, the patient is not directly included in the value proposition of the care provided.
Yet, it is the patient who actually receives the care, but their experiences (Triple Aim #1) are primarily presumed to be taken into account in the payment models currently used. In short, the patient’s voice is mysteriously (or purposely) missing at the reimbursement level. As a result, the deck of cards is currently stacked against the patient when determining ‘appropriate’ and ‘quality’ care. Their specific experience is rarely used, and if it is considered, it’s by aggregating the experiences of all patients for each given provider.
How then, can individual patient experience determine the price a provider is paid? A new approach is to allow each patient to have input on at least a portion of the provider reimbursement. Theory from this suggests the provider will be held more accountable for the care they give to EACH patient, and possibly learn more about how to make the patient experience a more positive encounter. Here’s a simple idea that may possibly hold some water.
Patient-Centered Value Movement
What do patients REALLY want from the healthcare providers they hire? Quality outcomes? Crystal clear communication and instructions? Clean hospital room and/or convenient parking? Delicious hospital food? Excellent bedside manners from nurses and doctors? Providers being considerate of the time it takes for patients to receive care? The short answer is ‘yes’ to all of the above. But each patient, given the circumstances of care they receive, will make their own unique analysis of what constitutes having a positive experience with any given provider.
A recent JAMA Forum article, “Payment Power to the Patients,” by Dr. Ashish K. Jha, a Harvard professor and practicing internist, provides a somewhat compelling case that the time has come for patients to jump into the reimbursement ‘game’ to determine at least a portion of pay for their caregivers. As Dr. Jha points out, assigning financial penalties or bonuses to providers based on a myriad of performance quality measures is difficult to achieve because consensus from providers and payers about how to define ‘high-value care’ is extremely difficult to determine.
His approach is actually quite simple. Thirty or 60 days following hospitalization, “every Medicare patient would be asked to evaluate the care they received and assign a payment to the hospital, which would determine up to 10 percent of the payment.” Jha uses the example of a pneumonia hospitalization that might have a standard CMS payment of $10,000, of which $9,000 would be guaranteed to the hospital, but 10 percent ($1,000) would be determined by the patient. Should a patient receive excellent care, based on his/her own personal experience, the full $1,000 would possibly be assigned to the hospital. Otherwise, if the patient perceived care to be below expectations, maybe only half would be assigned to the hospital.
From this process, hospitals and providers would need to become more astute about what is most important to their clientele – one patient at a time. Hospitals would, as Dr. Jha articulates, become “flexible and truly patient-centered, by meeting the varying needs and values of individual patients.”
Although Dr. Jha discusses this reimbursement program through Medicare, this approach, if successful, might also apply to the private payer markets, such as individual and employer-sponsored plans. Much work would be needed for this new payment incentive system to work, however.
To become more patient-centered, patients must be involved in deciding whether the care was of good quality for them, personally. The value movement must incorporate all three ‘Ps’, not just one or two. Immediate patient-experience feedback should also have direct consequences. From this, good behaviors by providers will be positively reinforced, while substandard behaviors would require modification when being identified soon after the delivery of care.
As with any reimbursement method, unintended consequences could emerge. But it may be worth the effort to at least try this approach.
What are your thoughts?
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