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Value-Based Medicine: Organizing IR Care through Integrated Practice Units
COMMENTARY
Value-Based Medicine: Organizing IR Care through Integrated Practice Units Michael Sarai, DO, MBA, Richard Duszak, Jr, MD, and John A. Kaufman, MD, MS ABBREVIATION IPU = integrated practice unit
In 2001, on the heels of its To Err Is Human report (1), the Institute of Medicine released Crossing the Quality Chasm (2), a road map for improving health care quality in the United States. This report implored all stakeholders to achieve major gains in six key areas: effectiveness, safety, patient-centeredness, efficiency, timeliness, and equity. It also spurred new funding for quality-ofcare research and health system redesign. However, by parsing quality as six arguably disparate elements, the Institute of Medicine report gave stakeholders license to define quality in various (and often competing) ways. Consequently, progress, particularly in patient-centeredness, has lagged far behind where it needs to be. In this regard, interventional radiology (IR) is no exception. The patient-centered quality chasm remains particularly wide where care is multidisciplinary, pathways to treatment are long and complex, and intervention is driven by expensive technology. In such cases, the onus to provide patient-centered value, rather than strictly quality, is especially important. But what is value, how it is different from quality, and why does this all matter for IR? In his seminal 2010 editorial, “What is value in healthcare,” Porter (3) described value as a ratio: a specific set of patient-centered outcomes achieved along the entire pathway of care relative to the total cost involved along the entire pathway of care. His “specific set of outcomes” refers to a hierarchy of outcomes, with From the College of Medicine (M.S.), Kansas City University, 1750 Independence Avenue, Kansas City, MO 64106; Department of Radiology and Imaging Sciences (R.D.), Emory University School of Medicine, Atlanta, Georgia; and Dotter Interventional Institute (J.A.K.), Oregon Health and Sciences University Hospital, Portland, Oregon. Received September 27, 2015; final revision received November 13, 2015; accepted November 14, 2015. Address correspondence to M.S.; E-mail: [email protected] None of the authors have identified a conflict of interest. & SIR, 2016 J Vasc Interv Radiol 2016; 27:336–338 http://dx.doi.org/10.1016/j.jvir.2015.11.038
survival being the highest value outcome, followed by patient-reported functional status, cycle time (time from diagnosis to recovery), and discomfort of treatment. Porter’s longitudinal view of patients’ travel through the health care system is the foundation of his definition. In considering outcomes and costs across the entire care pathway (eg, from disease prevention to disease recurrence), value-based medicine centers care around patient-specific outcomes. These are often very different from—and sometimes compete with—physician-specific (eg, adherence to evidence-based guidelines), diseasespecific (eg, surrogate markers), or hospital-specific (eg, infection rates) interests. Although a focus on non–patient-centered outcomes (or, perhaps more aptly, less patient-centered outcomes) may predict patient-centered outcomes, such an approach is often myopic, blinding health care systems from patients’ downstream needs (eg, minimizing work absenteeism, psychosocial health) and tempering potential value gains. Moreover, a focus on value, rather than on just “quality,” impels patients, their many providers, and payers to pursue a shared goal. Although the last statement may sound trite and perhaps condescending to physicians who intuitively attend to the preferences of their patients, it is important to recognize that society’s focus on quality—a heterogeneous and ill-defined measure of successful care—has led to a system of stakeholders with competing interests. The effect of competing interests has recently come to the fore in the management of type 2 diabetes, where an emphasis on surrogate markers has encouraged increasingly lower hemoglobin A1c targets (4). However, this practice may have very little benefit for mortality in type 2 diabetes (4,5). Furthermore, the focus on specific and easily measured “quality” metrics (eg, blood glucose targets, guideline adherence) has created a significant drug burden for diabetic patients (6) and has distracted from other important patient-centered interventions not included in those quality metrics (eg, lifestyle counseling).
Volume 27
’
Number 3
’
March
’
2016
Patient-centeredness is not necessarily an inherent attribute of quality-based medicine. Parallels exist for IR. How would IR look if care were prioritized more toward patient-centered processes? Establishing separate care systems for subpopulations of patients is a linchpin of value-based medicine. For example, patients with hepatic malignancy follow a remarkably different care pathway than patients with chronic renal failure. The IR residency, which promises to train interventional radiologists more thoroughly in nonprocedural care, is an important step in creating a more patient-oriented and disease-oriented specialty. Organizing training around specific medical conditions is a crucial next step. That is, more targeted training in specific care pathways would better align services with patients’ needs. Surely, an interventional radiologist treating a patient with unresectable hepatocellular carcinoma cannot maximize value by providing the same longitudinal care for a hemodialysis patient with a clotted fistula. The end goal of having interventional radiologists practice in more subspecialized manners would be to achieve better integration. To date, health care system designers have conceptualized “integration” as one-stop shop health care delivery systems, where integration is achieved across diseases—think of large multispecialty groups such as Kaiser Permanente or MD Anderson. IR is similarly organized. This type of organization nicely serves providers, who are able to maximize volume (and consequently their fee-for-service payments) by treating any one or more of a diverse group of patients that may walk through the door. However, when graduates of the
337
new IR residency are tasked with leading a clinic, skill in performing procedures will no longer be sufficient to create value for patients. Moving forward, interventional radiologists will have to focus on more than just the imaging-guided intervention; they will be accountable, either directly or by association, for the total care of their patients. The entire care pathway, from disease prevention to disease recurrence, and the outcomes associated with each step of the care pathway will be potentially within the purview of the interventional radiologist. In other words, interventional radiologists will have to integrate care within diseases. Such integration occurs best within Porter’s integrated practice units (IPUs) (Fig 1) (3), in which providers commit a substantial portion of their time to treating a focused set of clinical pathways. Such units consist of systems and multidisciplinary teams that are designed to care for the specific needs of their subset of patients. In IPUs, providers have a narrower scope of practice, but as a result, they have more time to attend to the entire care pathway. The evidence of benefits for this type of integration at the present time is scant but positive (7,8). Many, if not most, interventional radiologists practice in environments in which a narrower scope of practice may seem neither feasible nor desirable. However, key concepts of IPUs still apply. In these situations, careful attention to changes in local practice ecologies that encourage a more integrated approach is necessary. For example, consolidation of hospitals, practices, or payers may create environments in which patients are directed to certain practice locations for certain types of
Figure 1. Structure of care for a patient with hepatocellular carcinoma.
338
’
Commentary: Value-Based Medicine
care. In the present, participation in existing tumor boards and multidisciplinary clinical conferences can lay the groundwork for inclusion in IPUs in the future. The provision of outpatient nonprocedural care in a clinic or office setting similarly builds awareness and acceptance of interventional radiologists as committed participants in patient management. Although these activities are often viewed as a low priority by non-IR partners in many radiology practices, they nonetheless create critical foundations for more integrated care in the future. New care delivery models will almost certainly parallel new payment models. The narrower scope of IR practice necessitated by IPUs may coincide with reduced procedure volume and, under a fee-for-service payment model, reduced provider reimbursement. However, it could also result in increased referrals to physicians who choose to participate in IPUs, yielding outcomes that matter most to their target patient populations. In either regard, interventional radiologists would be rewarded not for sheer volume, but rather overall outcomes. This way, payers create value for their customers while motivating providers to provide value-based care. The practice of IR has changed dramatically over the last two decades. The context in which IR is practiced is likely continue to change with current quality metrics increasingly giving way to more patient-centered measures. To date, research in IR has traditionally focused on procedural innovation and conventional outcomes rather than on patient-reported outcomes. Future research should increasingly focus on our collective
Sarai et al
’
JVIR
beliefs that IR offers a short time to treatment, fast recovery, and few morbid complications. Efforts in this area will help support the broad patient acceptance that will be essential for the future of the specialty. Such outcomes are likely to be key components of evolving pay-for-performance reimbursement schemes. A spirit of innovation has existed in our field since Dr. Dotter performed the first angioplasty. When we broaden the focus of our ingenuity to include the science of improving health care delivery, interventional radiologists could yet again revolutionize medicine.
REFERENCES 1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. 2. Kohn LT, Corrigan JM, Donaldson MS, eds. Crossing the Quality Chasm: A New Health System for the 21st Century. 1st ed. Washington, DC: National Academy Press; 2001. 3. Porter ME. What is value in health care? N Engl J Med 2010; 363: 2477–2481. 4. Yudkin J, Richter B, Gale E. Intensified glucose lowering in type 2 diabetes: time for a reappraisal. Diabetologia 2010; 53:2079–2085. 5. Ray KK, Seshasai SRK, Wijesuriya S, et al. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. Lancet 2009; 373: 1765–1772. 6. Huang ES, Brown SES, Ewigman BG, Foley EC, Meltzer DO. Patient perceptions of quality of life with diabetes-related complications and treatments. Diabetes Care 2007; 30:2478–2483. 7. Chan CK, Chan G. The shouldice technique for the treatment of inguinal hernia. J Minim Access Surg 2006; 2:124–128. 8. Abdulla AG, Ituarte PHG, Wiggins R, Teisberg EO, Harari A, Yeh MW. Endocrine surgery as a model for value—based health care delivery. Surg Neurol Int 2012; 3:1–12.
Value-Based Medicine: Organizing IR Care through Integrated Practice Units Michael Sarai, DO, MBA, Richard Duszak, Jr, MD, and John A. Kaufman, MD, MS ABBREVIATION IPU = integrated practice unit
In 2001, on the heels of its To Err Is Human report (1), the Institute of Medicine released Crossing the Quality Chasm (2), a road map for improving health care quality in the United States. This report implored all stakeholders to achieve major gains in six key areas: effectiveness, safety, patient-centeredness, efficiency, timeliness, and equity. It also spurred new funding for quality-ofcare research and health system redesign. However, by parsing quality as six arguably disparate elements, the Institute of Medicine report gave stakeholders license to define quality in various (and often competing) ways. Consequently, progress, particularly in patient-centeredness, has lagged far behind where it needs to be. In this regard, interventional radiology (IR) is no exception. The patient-centered quality chasm remains particularly wide where care is multidisciplinary, pathways to treatment are long and complex, and intervention is driven by expensive technology. In such cases, the onus to provide patient-centered value, rather than strictly quality, is especially important. But what is value, how it is different from quality, and why does this all matter for IR? In his seminal 2010 editorial, “What is value in healthcare,” Porter (3) described value as a ratio: a specific set of patient-centered outcomes achieved along the entire pathway of care relative to the total cost involved along the entire pathway of care. His “specific set of outcomes” refers to a hierarchy of outcomes, with From the College of Medicine (M.S.), Kansas City University, 1750 Independence Avenue, Kansas City, MO 64106; Department of Radiology and Imaging Sciences (R.D.), Emory University School of Medicine, Atlanta, Georgia; and Dotter Interventional Institute (J.A.K.), Oregon Health and Sciences University Hospital, Portland, Oregon. Received September 27, 2015; final revision received November 13, 2015; accepted November 14, 2015. Address correspondence to M.S.; E-mail: [email protected] None of the authors have identified a conflict of interest. & SIR, 2016 J Vasc Interv Radiol 2016; 27:336–338 http://dx.doi.org/10.1016/j.jvir.2015.11.038
survival being the highest value outcome, followed by patient-reported functional status, cycle time (time from diagnosis to recovery), and discomfort of treatment. Porter’s longitudinal view of patients’ travel through the health care system is the foundation of his definition. In considering outcomes and costs across the entire care pathway (eg, from disease prevention to disease recurrence), value-based medicine centers care around patient-specific outcomes. These are often very different from—and sometimes compete with—physician-specific (eg, adherence to evidence-based guidelines), diseasespecific (eg, surrogate markers), or hospital-specific (eg, infection rates) interests. Although a focus on non–patient-centered outcomes (or, perhaps more aptly, less patient-centered outcomes) may predict patient-centered outcomes, such an approach is often myopic, blinding health care systems from patients’ downstream needs (eg, minimizing work absenteeism, psychosocial health) and tempering potential value gains. Moreover, a focus on value, rather than on just “quality,” impels patients, their many providers, and payers to pursue a shared goal. Although the last statement may sound trite and perhaps condescending to physicians who intuitively attend to the preferences of their patients, it is important to recognize that society’s focus on quality—a heterogeneous and ill-defined measure of successful care—has led to a system of stakeholders with competing interests. The effect of competing interests has recently come to the fore in the management of type 2 diabetes, where an emphasis on surrogate markers has encouraged increasingly lower hemoglobin A1c targets (4). However, this practice may have very little benefit for mortality in type 2 diabetes (4,5). Furthermore, the focus on specific and easily measured “quality” metrics (eg, blood glucose targets, guideline adherence) has created a significant drug burden for diabetic patients (6) and has distracted from other important patient-centered interventions not included in those quality metrics (eg, lifestyle counseling).
Volume 27
’
Number 3
’
March
’
2016
Patient-centeredness is not necessarily an inherent attribute of quality-based medicine. Parallels exist for IR. How would IR look if care were prioritized more toward patient-centered processes? Establishing separate care systems for subpopulations of patients is a linchpin of value-based medicine. For example, patients with hepatic malignancy follow a remarkably different care pathway than patients with chronic renal failure. The IR residency, which promises to train interventional radiologists more thoroughly in nonprocedural care, is an important step in creating a more patient-oriented and disease-oriented specialty. Organizing training around specific medical conditions is a crucial next step. That is, more targeted training in specific care pathways would better align services with patients’ needs. Surely, an interventional radiologist treating a patient with unresectable hepatocellular carcinoma cannot maximize value by providing the same longitudinal care for a hemodialysis patient with a clotted fistula. The end goal of having interventional radiologists practice in more subspecialized manners would be to achieve better integration. To date, health care system designers have conceptualized “integration” as one-stop shop health care delivery systems, where integration is achieved across diseases—think of large multispecialty groups such as Kaiser Permanente or MD Anderson. IR is similarly organized. This type of organization nicely serves providers, who are able to maximize volume (and consequently their fee-for-service payments) by treating any one or more of a diverse group of patients that may walk through the door. However, when graduates of the
337
new IR residency are tasked with leading a clinic, skill in performing procedures will no longer be sufficient to create value for patients. Moving forward, interventional radiologists will have to focus on more than just the imaging-guided intervention; they will be accountable, either directly or by association, for the total care of their patients. The entire care pathway, from disease prevention to disease recurrence, and the outcomes associated with each step of the care pathway will be potentially within the purview of the interventional radiologist. In other words, interventional radiologists will have to integrate care within diseases. Such integration occurs best within Porter’s integrated practice units (IPUs) (Fig 1) (3), in which providers commit a substantial portion of their time to treating a focused set of clinical pathways. Such units consist of systems and multidisciplinary teams that are designed to care for the specific needs of their subset of patients. In IPUs, providers have a narrower scope of practice, but as a result, they have more time to attend to the entire care pathway. The evidence of benefits for this type of integration at the present time is scant but positive (7,8). Many, if not most, interventional radiologists practice in environments in which a narrower scope of practice may seem neither feasible nor desirable. However, key concepts of IPUs still apply. In these situations, careful attention to changes in local practice ecologies that encourage a more integrated approach is necessary. For example, consolidation of hospitals, practices, or payers may create environments in which patients are directed to certain practice locations for certain types of
Figure 1. Structure of care for a patient with hepatocellular carcinoma.
338
’
Commentary: Value-Based Medicine
care. In the present, participation in existing tumor boards and multidisciplinary clinical conferences can lay the groundwork for inclusion in IPUs in the future. The provision of outpatient nonprocedural care in a clinic or office setting similarly builds awareness and acceptance of interventional radiologists as committed participants in patient management. Although these activities are often viewed as a low priority by non-IR partners in many radiology practices, they nonetheless create critical foundations for more integrated care in the future. New care delivery models will almost certainly parallel new payment models. The narrower scope of IR practice necessitated by IPUs may coincide with reduced procedure volume and, under a fee-for-service payment model, reduced provider reimbursement. However, it could also result in increased referrals to physicians who choose to participate in IPUs, yielding outcomes that matter most to their target patient populations. In either regard, interventional radiologists would be rewarded not for sheer volume, but rather overall outcomes. This way, payers create value for their customers while motivating providers to provide value-based care. The practice of IR has changed dramatically over the last two decades. The context in which IR is practiced is likely continue to change with current quality metrics increasingly giving way to more patient-centered measures. To date, research in IR has traditionally focused on procedural innovation and conventional outcomes rather than on patient-reported outcomes. Future research should increasingly focus on our collective
Sarai et al
’
JVIR
beliefs that IR offers a short time to treatment, fast recovery, and few morbid complications. Efforts in this area will help support the broad patient acceptance that will be essential for the future of the specialty. Such outcomes are likely to be key components of evolving pay-for-performance reimbursement schemes. A spirit of innovation has existed in our field since Dr. Dotter performed the first angioplasty. When we broaden the focus of our ingenuity to include the science of improving health care delivery, interventional radiologists could yet again revolutionize medicine.
REFERENCES 1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. 2. Kohn LT, Corrigan JM, Donaldson MS, eds. Crossing the Quality Chasm: A New Health System for the 21st Century. 1st ed. Washington, DC: National Academy Press; 2001. 3. Porter ME. What is value in health care? N Engl J Med 2010; 363: 2477–2481. 4. Yudkin J, Richter B, Gale E. Intensified glucose lowering in type 2 diabetes: time for a reappraisal. Diabetologia 2010; 53:2079–2085. 5. Ray KK, Seshasai SRK, Wijesuriya S, et al. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. Lancet 2009; 373: 1765–1772. 6. Huang ES, Brown SES, Ewigman BG, Foley EC, Meltzer DO. Patient perceptions of quality of life with diabetes-related complications and treatments. Diabetes Care 2007; 30:2478–2483. 7. Chan CK, Chan G. The shouldice technique for the treatment of inguinal hernia. J Minim Access Surg 2006; 2:124–128. 8. Abdulla AG, Ituarte PHG, Wiggins R, Teisberg EO, Harari A, Yeh MW. Endocrine surgery as a model for value—based health care delivery. Surg Neurol Int 2012; 3:1–12.