In the coming years, the most dramatic change in medicine in the United States will be the organizational transformation of the health care delivery system. Historically, the public narrative on medical care highlighted its lifesaving power with little mention of cost. More recently, the inexorable growth in health care spending has forced a critical examination of the value of services delivered.
Impending delivery system changes will be shepherded by the Patient Protection and Affordable Care Act (ACA), signed into law in 2010 with critical provisions upheld by the Supreme Court in 2012. Along with insurance reform, the ACA experiments with payment reform—replacing the traditional fee-for-service model with new reimbursement models that focus on cost, quality, and outcomes. Organizations—including academic health centers—able to achieve the same or better outcomes for less, while maintaining or exceeding quality standards and delivering patient-centered care, will be the likely financial winners of the future. Payment changes that reward value will create enormous incentives to focus on cost-conscious care while expanding ways to monitor and improve quality.
For medical educators, the question is how to prepare the next generation of physicians for this fundamental change in American medicine. In response to this challenge, many academic health centers have developed new “innovation” or “value” institutes charged with promoting cost-consciousness and clinical practice innovation. At George Washington University School of Medicine and Health Sciences, for example, the Office for Clinical Practice Innovation opened in mid-2013 with the mission of engaging and educating faculty, fellows, residents, and students in clinical practice innovation.1 Clinical practice innovation is about developing and evaluating new ways to deliver care that enhance value, reduce cost, improve quality, and elevate the patient experience.
Several other universities and health systems have started similar institutes, with varied objectives. Some have focused innovation efforts on technology transfer; for example, Cleveland Clinic Innovations focuses on bringing new health care innovations to market.2 By comparison, the Penn Medicine Center for Health Care Innovations focuses on cultural change to promote innovation, connected health, and employee wellness, an important economic consideration for self-insured systems.3
While the effectiveness of some of these academic innovation institutes remains to be seen, many are focused in part on surmounting barriers to value-based care in academic health centers. Structural and cultural changes will be required for academic health centers to compete in the market as new payment models and quality measurement programs evolve.
One major barrier is that medical faculty may strongly resist the new trend toward value-based care: Explicit consideration of cost in medical decision making may feel antithetical to their training. In addition, most academic physicians today order medicines, tests, and treatments without knowing what the “cost” is—that is, the amount ultimately charged to a patient’s insurer, what the insurer has contracted to pay, and what part of the cost may be passed on to the patient. The knowledge gap concerning medical economics is not surprising given that many academic health centers consider pricing and reimbursement rates proprietary.
Therefore, the first challenge for innovation institutes is to broadly engage faculty in discussions of cost-conscious care. Where possible, these discussions should include local price or cost data and should be communicated through lectures, small-group meetings, and town halls. Medical students and house staff also should participate in these discussions, not only because of their role in day-to-day treatment decisions but also to prepare them for their future role in value-based and cost-conscious care.
Another barrier to cost-conscious care is the approach to residency training in the United States, where residents are expected to have sufficient autonomy to develop their own practice style. This notion conflicts with the process uniformity which characterizes quality improvement methods drawn from other industries (e.g., Six Sigma) and even in selected areas of medical practice where checklists and protocols have improved performance (e.g., anesthesia, surgery, emergency medicine, and ventilator management in the intensive care unit).
A greater emphasis on standardization, cost, and outcomes may compel academic physicians to oversee testing and treatment decisions more closely. In many institutions, this change in focus will be a departure from the previous training paradigm. Innovation institutes can lead explicit discussions on how to ensure that residents learn effectively in a value-based environment. Rather than learning by doing, residency training in such an environment may be more focused on learning by example with more oversight from faculty.
Faculty will also need to better teach learners how to employ concepts related to communication and customer service, which are often absent from current clinical curricula. These skills will be increasingly important in value-based medical care where providers will be paid differently according to how patients rate their experience using surveys. Quality metrics, another key element of delivery system reform, have seen greater integration into academic medical practice because of public reporting and accreditation requirements. As an example, tremendous efforts have been invested in the early identification and treatment of patients with acute myocardial infarction (AMI), in part because the percentage of patients with AMI who receive percutaneous reperfusion within 90 minutes is a publicly reported quality measure for hospitals.4
However, over the past few years, quality measurement is shifting from process to outcome metrics, a trend that will likely continue. Outcome metrics include complications, how patients rate their care experience, and mortality. Current residency training emphasizes provision of the best care but frequently neglects to provide explicit instruction in quality improvement and clinical leadership. For example, certain academic health centers have higher-than-average AMI death rates that are publicly reported. Although data do exist on how these academic health centers might improve their performance by adopting best practices,5 how to change and sustain a practice through leadership has not historically been a major focus of residency training.
Innovation institutes may offer a forum to discuss local barriers to quality and engage multidisciplinary teams in fostering a culture of safety and quality improvement. In so doing, they may facilitate adoption of proven strategies to improve institutional outcomes and teach residents how to implement new practices effectively. In addition, innovation institutes would need to bridge the clinical and education silos and bring in expertise from health policy and health services research.
The development and integration of curricula for undergraduate medical education (UME) and graduate medical education (GME) relevant to safety and quality improvement is an important starting place. Working collaboratively with UME curricular deans and course directors, innovation institutes can assist in the incorporation of relevant learning objectives, content, and clinical reasoning exercises for preclinical courses, clerkships, and fourth-year capstone courses. Similarly, by meeting regularly with the committee of residency program directors within a medical school’s Office of GME, innovation institutes can support the development of relevant curricula for all residents and within specialties.
In academic health centers, medical students and residents should not only be included in quality improvement teams but also should be encouraged to take leadership roles. The Accreditation Council for Graduate Medical Education (ACGME) requires that U.S. residents complete a quality improvement project as part of their residency education. Innovation institutes can coordinate this activity with the Office of GME and help disseminate insights from this work within the institution, through the peer-reviewed literature, and through their participation in the ACGME’s new Clinical Learning Environment Review (CLER) process. CLER seeks to answer several questions, including how sponsoring institutions support and measure success (or opportunities for improvement) in integrating quality improvement and patient safety measures into the clinical learning environment for residents.
Also key to performance improvement are registries that can be used to compare processes and outcomes across sites. A notable example is the American College of Cardiology–sponsored National Cardiovascular Data Registries (NCDR).6 The Society for Thoracic Surgeons has also created a registry that can aid in reducing the administrative burden of data reporting and may be used for quality improvement.7
Although many registries do not contain data on costs of care, comparisons on utilization of diagnostic testing or other clinically meaningful units may be a way to explore differences in care across sites. Innovation institutes can work to bring together groups of physicians across institutions to discuss variations in practice that are evident in registry data or even claims data, which may give greater transparency to data on cost variation. Through explicit discussions about variation and how this leads to cost differences, institutions can also share best practices on management strategies for particular clinical entities (e.g., comparing the costs and resources used across facilities for treating a patient with a new diagnosis of heart failure) and relate these practices to clinical outcomes.
Cross-institutional innovation groups can serve as a mechanism to educate faculty, residents, and medical students on new payment models and quality metrics. They can also engage faculty leadership within departments to focus on clinical quality improvement and to closely examine value. They can provide tools to faculty, residents, and medical students to enhance awareness on costs of care, and help mentor leaders within departments to create and sustain successful quality and value improvement programs.
Another pervasive issue hindering cost-consciousness efforts is “defensive medicine,” which permeates both academic and nonacademic medicine. Although legal scholars point to the weak relationship between changing malpractice laws and changes in medical care intensity,8 defensive medicine goes far beyond malpractice fear. The culture of medicine in the United States today places much greater penalties on undertreatment and missed diagnosis than on overtreatment and overdiagnosis. For physicians, a missed diagnosis or opportunity to intervene today may mean presenting the case in front of colleagues in morbidity and mortality conferences and, in very rare cases, in litigation.
Innovation institutes may engender a culture of safety and cost-consciousness and prompt discussions about which practices are evidence based. Unfortunately, in the United States, attitudes toward medical risk, a proclivity for assigning blame when bad outcomes occur, and widespread denial that medical resources are finite will remain barriers to value-based health care for some time to come.
Ultimately, innovation institutes cannot address every obstacle to value-based health care in academic health centers. However, initiatives like these are critical if we are going to optimize the value of our tremendous national investment in health care. Innovation institutes can ensure that academic health centers optimize their teaching and research missions while remaining competitive as payment reforms evolve.