Since the implementation of the Affordable Care Act (ACA) in March 2010, there has been tremendous “across-the-aisle” discussion about health care access and cost, but not as much about quality, health care executive Rohit Bhalla told an audience at Sacred Heart University’s new Center for Healthcare Education (CHE) recently.
Bhalla delivered a presentation, “Value in Healthcare: What is it, and is it working?” as part of the CHE’s Inaugural Year Lecture Series. Patricia Walker, dean of SHU’s College of Health Professions, sponsored the hour-long talk.
Bhalla is vice president and chief quality officer at Stamford Heath; associate clinical professor of medicine at Columbia University College of Physicians and Surgeons and a member of SHU’s Physician Assistant Advisory Committee. He was introduced by Teresa Thetford, chair of the University’s Physician Assistant Studies, who related that Bhalla is responsible for the oversight of such areas as quality, patient safety and care management, and that he is “a kind, caring and compassionate physician.” To the audience, many of whom were students in health care education, she added, “These are important, if not absolutely integral roles, as you learn your clinical skills to be a clinician in your area or profession.”
Bhalla’s presentation focused on value (which he defined as quality over cost, where cost is the same but outcomes are better) and health care from a provider perspective: why it’s important, has it worked and what’s next. In the U.S., where health care spending has topped $3.2 trillion, or nearly $9,000 per person (the same as Germany’s gross domestic product, which is the fourth-highest in the world), it’s no wonder this is a hot topic.
With all that spending, Bhalla asked, are we actually getting something in return? Historically (over the past 40-50 years), there has been a drastic decline in death rates and an increase in life expectancy, due in part to cholesterol-lowering agents, anti-smoking measures and diabetes treatment, he said. In fact, he noted, there has been a 50 percent reduction in cardiovascular death rates on an age-adjusted basis. Yet, a 1999 study by the Institute of Medicine (IOM) that evaluated health care quality found that more than 100,000 people died each year in hospitals as a result of medical errors. That startling number “launched the entire quality/safety movement from which value came,” said Bhalla.
While advances had been made, were treatments effective? Bhalla cited the same IOM study that showed only 55 percent of people were receiving recommended care, or their conditions were controlled. Further, a study of health care spending and outcomes among Medicare beneficiaries by Surgeon Atul Gawande, published in The New Yorker in 2009, showed as much as 100 percent variability among people in the same demographic.
These studies inspired the government to think, “We could save a lot of money by focusing on value and standardizing care,” Bhalla said. It initiated a move to require hospitals to publicly report care, begin measuring their performance and to pay them differentially according to results. This was the earliest ACA experiment, looking at care factors including appropriateness, coordination, safety, effectiveness and patient experience.
Has this new approach worked? Bhalla noted a 2005-2010 study, “Quality & Equity of Care in U.S. Hospitals,” published in 2014 in the New England Journal of Medicine, that showed large improvements. Another study, published in December 2016 by the Agency for Healthcare Research and Quality, showed a decrease in hospital-acquired conditions and U.S. inpatient mortality. Further, a review by the U.S. Department of Health & Human Services of a 30-day period in 2014 show a decrease in readmission rates for Medicare patients.
The data are encouraging, while provoking the question “Which is more important in driving better care: necessity of reporting or differential payments?” Bhalla sides with reporting, citing a study showing a reduction in mortality from adult cardiac surgery in 2012-2014 in New York State when there was no differential payment incentive.
In the past, Bhalla said, medical professionals based their care on a financial model— the more patients a doctor saw, the more that doctor got paid. Now the trend among doctors follows a different model: the more outcomes improve, the more they get paid—a shift from quantity to quality. Bhalla says this move is increasing communication and collaboration at all provider touchpoints. Further, report cards are becoming prominent and are used as competitive tools. Bhalla said that now, individual physicians’ performances are measured, and a push is on for greater efficiency and care coordination.