The Case for Care Transformation

Albert Einstein is credited with a pithy definition that insanity is: “Doing the same thing over and over again and expecting different results.” By that definition, the U.S. health care system has been on an “insane” path for too long. Our fee-for-service payment model has rewarded volume of services over high-quality, coordinated care for decades. The results we get, year after year, are skyrocketing costs totaling $3.8 trillion in spending in 2019 with a growth trajectory to reaching $6.0 trillion by 2027[1]. To put this in perspective, If the U.S. health care were its own country, it would be the 4th largest economy in the world.

We don’t get much for our spending either. We have the 55th highest infant mortality in the world (tied with Serbia)[2], our life expectancy ranks 43rd in the world[1], and we are nearly 3 times more likely to die of coronary heart disease than someone in South Korea.[3]

Perhaps finally taking heed of the famous Einstein quote, policy makers, payers, providers and patients are now looking to do things differently. These efforts are embodied in the concept of care transformation. Care transformation has become a favorite talking point and shared aspiration for a range of health care organizations. In fact, new Chief Clinical Transformation Officer roles are popping up at provider and payer organizations around the country, including organizations such as the Cleveland Clinic and Horizon Blue Cross Blue Shield of NJ.

But what exactly does care transformation actually mean?

I have the chance to see our health care system through multiple lenses, as a researcher, a physician, a father, a patient, and a business owner. In each of these roles, my view of care transformation is pretty straightforward: Care will be transformed when we offer consistent, evidence-based care that achieves the best possible outcomes at the lowest possible cost.

The clear conclusion from my health economics research, done around the world, is that health systems delivering consistent, evidence-based care deliver the highest value care to patients. Access to evidence-based care supported by the best available science is what drives the best outcomes when I see patients in the clinic. Consistently high-quality care is what I hope I receive when my children or I need medical attention. And avoiding low-value, high-cost services are key to keeping premiums low so I’m able to invest in my employees and product.

Care transformation through consistent, evidence-based care can only become a reality when we address what I consider to be a preventable national health crisis – unwarranted care variation. For too many years, we have been working under the same old incentives and training protocols that lead to a wide range of medical practices for the same conditions. This variation, we and others have shown clearly, can’t be explained by the severity of illness or patient preferences. This unwarranted variation is routinely observed between states, zip codes, and even between providers in the same facility.

For example, those visiting a bottom decile hospital more than double their chances of dying compared to a top decile hospital[4]. The incidence of central venous catheter blood stream infection is nearly 20 times higher at a bottom decile hospital[3]. Someone in Idaho Falls is three times more likely to undergo knee replacement surgery than a patient in the Bronx[5].

Variation like this negatively affects outcomes, experience and cost. We can all agree that where you live or which doctor you happen to see should never dictate the level or type of care received, yet the stories of care disparity are endless.

Our research and work in the U.S. indicate that most of this variation is avoidable. While evidence-based guidelines do not cover every potential clinical scenario, there is overwhelming evidence that high-quality guidelines across many common conditions are under-utilized by well-meaning, hardworking, busy clinicians struggling to keep up with the latest guidelines. Collectively, the decisions these providers make every day influence a staggering 80% of all health care spending[6].

There are a number of tools today that seek to address unwarranted variation, such as quality dashboards, EHR clinical decision support and changing incentive models. However, most of these tools have struggled to transform practice at scale through more consistent care. The missing piece, in my opinion, is true clinical collaboration with physicians in this care transformation journey.

Medicine is hard and any attempt to truly transform care, to do things differently, must actively engage providers on the front lines and arm them with the training and tools they need to make the best, most evidence-based decision they can for every patient they see. This is an essential part of getting the different results – high quality, high value – that unites these care transformation efforts.

Whether you have Clinical Transformation in your job title or not, reducing unwarranted variation will be critical to successful care transformation and to succeeding in the new value-based models, such as ACOs and capitated payments, that seek to reward organizations that do things differently to get different results.

If we can successfully bring consistency back to care and reduce unwarranted variance, we will all benefit through higher quality, better outcomes and lower costs.

 

[1] National Health Expenditure Projections 2018-2027, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/ForecastSummary.pdf, Accessed February 2020.

[2] CIA World Fact Book, https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html, Accessed February 2020.

[3] World Health Organization, Age Adjusted Death Rate Estimates: 2017

[4] Rosenberg BL, Kellar JA, Labno A, et al. Quantifying Geographic Variation in Health Care Outcomes in the United States before and after Risk-Adjustment. Plos One. 2016;11(12). doi:10.1371/journal.pone.0166762

[5] The data was obtained from The Dartmouth Atlas, which is funded by the Robert Wood Johnson Foundation and the Dartmouth Clinical and Translational Science Institute, under award number UL1TR001086 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH).

[6] Crosson FJ. Change the microenvironment. Delivery system reform essential to control costs. Mod Healthc. 2009;39(17):20–21.

 

About The Author

Employee Spotlight: Honey Holman

As a nursing education specialist with Ascend business ATI Nursing Education, Honey Holman creates and revises content for exams, practice exams, tutorials and video scripts for nursing students. The NCLEX test (which students must pass to become a practicing nurse) is updated every three years and many of ATI’s products are updated on the same schedule to help learners and educators stay current with references and practices. Honey also keeps her team’s handbook updated for common processes and tasks, and trains consultants who assist with item review.

When she’s not working, you can find Honey spending time with her family – especially during family nights at her house, which consist of board games, movies and themed meals. She’s also involved with her church and helps with leading and serving there.

Q. What does an average day look like for you and your job?

A. Currently I am helping lead the update of our nursing Skills product. This product includes learning material and videos focused on skills general nurses need to perform on the job, such as inserting and caring for intravenous lines, feeding tubes, vital sign assessment, and airway and oxygen management. Beyond this project, my typical day is split between writing items or learning content and reviewing created content, including meeting other nurse and test developer colleagues to prepare assessments. Essentially, our team produces the “meat” for all the content across our products that nursing students will use.

Q. What is your favorite thing about the business unit or department you support?

A. Our team of nurses is brilliant. We all have different areas of expertise from our varied practice backgrounds. We have good relationships and can collaborate with each other when we need a second opinion or to gain the advice of a peer who has more experience in a certain aspect of nursing.

Q. As a follow up, what is one word that you would use to describe your work team?

A. Resilient. We balance each other well with varied personalities and expertise, and there is a deep commitment to the team. When you practice nursing in a clinical setting, covering each other’s breaks and taking extra shifts when a team member is down becomes second nature and so we apply the same care in this working environment. We work together well and there is great give and take that keeps us moving forward no matter what professional or personal difficulties come up.

Q. What’s the best thing about the city you live in?

A, We live in a small town in Alabama that is also home to the country singing group Alabama, who kindly built a really nice park with a walking trail and exercise equipment where my daughters love to play. We enjoy town parades, festivals and fairs that all give it that nice, homey small-town charm. We also have access to the mountains, and it’s far enough north that we get to experience all four true seasons each year.

 

 

Jones & Bartlett Learning Offers Free Online Educational Resource for Mechanical Ventilation Clinicians

In response to the COVID-19 pandemic, Jones and Bartlett Learning announced that they will be providing Essentials of Mechanical Ventilation, a free online educational resource for clinicians as well as important information regarding the more common ventilators they may encounter in hospitals today.

In continued response to the COVID-19 pandemic and the on-going need for mechanical ventilation, Jones and Bartlett Learning, an Ascend Learning Company, announced today that they will be providing Essentials of Mechanical Ventilation, a free online educational resource for clinicians, which outlines the initiation and adjustment of ventilator support, as well as important information regarding the more common ventilators they may encounter in hospitals today.

“As we continue to live in a new reality amongst COVID-19 we thank those in the medical field fighting day and night aiding those in need and advancing our knowledge of the disease” said Cathy Esperti, Director of Product Management, Jones & Bartlett Learning. “We are hopeful that this resource will assist them in the field as they work with COVID-19 patients.”

Essentials of Mechanical Ventilation is a product associated with the award winning text Mechanical Ventilation by David C. Shelledy, PhD, RRT, RPFT, FAARC, FASAHP and Jay I. Peters, MD. The comprehensive guide covers the evaluation and management of critically ill patients requiring mechanical ventilatory support, techniques, and procedures for providing safe and effective mechanical ventilation. This online resource will provide clinicians essential information on when to start a patient on a ventilator and how to initiate and adjust ventilation. Essentials of Mechanical Ventilation also includes a Comprehensive Mechanical Ventilation Synopsis Deck, comprised of 1000 slides in PowerPoint™ format, which provides an overview of various ventilator types arranged by Critical Care Ventilators; High-Frequency Ventilators; Portable, Transport, and Non-invasive Ventilators; and Neonatal Ventilators. Jones and Bartlett Learning also offers a full Respiratory Care Curriculum providing robust resources for hospitals, clinicians, and educators.

“In this era of the COVID-19 pandemic, mechanical ventilation can be a lifesaving intervention when applied properly by skilled clinicians,” said Shelledy. “I am delighted that Jones & Bartlett has made these detailed and up-to-date training materials available to the outstanding clinicians caring for critically ill patients in the ICUs and emergency departments of our hospitals. I hope the materials are useful to them as they seek to provide the very best care to their patients. Godspeed and stay safe!”

About Jones & Bartlett Learning
Jones & Bartlett Learning is a world-leading provider of instructional, assessment, and learning-performance management solutions for the secondary education, post-secondary education, and professional markets. Jones & Bartlett Learning develops educational programs and services that improve learning outcomes and enhance student achievement by combining authoritative content written by respected authors with innovative, proven, and engaging technology applications that meet the diverse needs of today’s instructors, students, and professionals. Learn more at http://www.jblearning.com.