There Is Light at the End of the Quality Tunnel: Physicians Are Starting to Drive the Bus

I am becoming more optimistic as I continue to understand and refine the programs of VillageHealth, the DaVita integrated care–management organization, and delve into the incredible success of HealthCare Partners, DaVita’s new partner. This optimism is driven by the belief that physician-led, physician-driven, patient-centric care can not only be accomplished, but such an approach optimizes clinical outcomes while responsibly controlling costs.

A recent set of papers in The New England Journal of Medicine helped fuel this optimism, as well, and begin to outline a “path forward” to make this happen (1,2). Thomas H. Lee, internist, cardiologist and health-policy guru, described what is needed for providers to drive and embrace clinical-care redesign, including key aspects of strategy, tactics and operations. While the concepts seem intuitive and simple, implementing them successfully is challenging for physicians working independently or in groups or organizations.

First, there must be an explicit strategy clearly articulating what the physician or organization is trying to accomplish, developed with a focus on what matters most to patients. Implicit in this is an absolute commitment to not only defining important outcomes, but also to measuring them in a transparent and reproducible way. It is important that important outcomes are measured even if the evidence behind them is imperfect. The goal is not to conduct an academic exercise, but to assist physicians in decreasing variations in care and outcomes and to enable application of best knowledge and practice at the time. When he speaks of “outcomes that matter,” Lee emphasizes that “hard outcomes (e.g., mortality) are…important, and doing significantly worse than expected…represents a major crisis. But…many such outcomes are largely determined by disease severity, it may be difficult or impossible for organizations to improve beyond the expected range.” This suggests that not only relevant outcomes, but also new methods of collecting, analyzing and reporting such data may be needed to fully capture the multidimensional aspects of quality.

Second, specific tactics must be developed to enable deployment of the strategic approaches described. Care-design teams must get into the trenches of patient care. Care processes need to be mapped in detail and then care re-engineered to be more efficient, outcomes-driven, and patient-centric. There must be continual feedback to make sure care teams understand the care processes and receive data in real time to reinforce the steps needed to optimize outcomes. This is a process that needs to be done at the local level, where care is delivered. While templates for best practices for care processes are a good starting point, all healthcare is local and customization is needed to take into account local patient characteristics, physician practice patterns and community resource availability.

Finally, none of this can happen without a strong commitment to teams—multi-disciplinary teams that not only provide the hands-on care, but also work together to develop the systems of care described above. The purpose in the end, as Lee states, is to “improve the value of care.”

Of course, we know that we operate largely in the world of a public payer, Medicare. How can we apply these principles to the Medicare-served, chronically ill, ESRD population? The second recent paper, coauthored by Patrick Conway, the CMO of CMS, suggests that our primary public payer is trying to move in the direction Dr. Lee suggests. CMS has now embraced the “triple aim” of the American healthcare system: better outcomes for individuals, better outcomes for populations, and lower overall costs. One of the tools being used is a movement to value-based purchasing—in ESRD, the Quality Incentive Program. Articulated in this paper are the five key principles that are important in driving value: 1. The end goal must be defined; 2. Provider incentives must be aligned; 3. The right measures must be developed and implemented rapidly; 4. Improvement as well as absolute performance must be supported; 5. The clinical community and patients must be actively involved in the process. Not very different from the overall redesign needs described by Lee.

At the end of the day change is always difficult, and in healthcare this has proven to be particularly the case. VanLare and Conway state, “Shifting to a culture of shared accountability for patient and community outcomes and costs will be a journey…”—one that Lee concurs will not be short or easy: “The approach to redesigning care requires the humility to concede that we are not as good as we can or should be, that we can learn from others, and that we need tools…to improve.…” Certainly in nephrology we cannot be satisfied with the outcomes of our patients with CKD/ESRD.

As integrated-care management, whether through ACOs or other vehicles, rapidly becomes an important approach to the care of the chronically ill, nephrologists have an opportunity to drive the teams that can make the “triple aim” a reality. This is being done today by HealthCare Partners as well as VillageHealth.

Business magnate and philanthropist Warren Buffett could have been describing healthcare in America, and certainly the care of the complex, chronically ill when he said,

“In a chronically leaking boat, energy devoted to changing vessels is more productive than energy devoted to patching leaks.”

Striving to bring quality to life,
Allen R. Nissenson, MD

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1. Lee TH. Care Redesign—A Path Forward for Providers. N Engl J Med 367:466, 2012.
2. 2. VanLare JM, Conway PH. Value-Based Purchasing—National Programs to Move from Volume to Value. N Engl J Med 367:292, 2012.