By Brent C. James and Lucy A. Savitz
Health Affairs, May 19, 2011
Since 1988 Intermountain Healthcare has applied to health care delivery the insights of W. Edwards Deming’s process management theory, which says that the best way to reduce costs is to improve quality.
Intermountain Healthcare is an integrated delivery system based in Utah and Idaho. Its network of twenty-three hospitals and 160 clinics provides more than half of all health care delivered in the region. Intermountain’s hospitals range from critical-access facilities in rural areas to large, urban teaching hospitals. Although Intermountain has an employed physician group and a health insurance plan, the majority of its care is performed by independent, community-based physicians and is paid for by government and commercial payers.
In 1986 an Intermountain team launched an effort to measure practice variation, focusing on the details of care in specific, common treatments.
What Intermountain Learned
First, most hospital admissions for a specific treatment had similar characteristics. Even for coronary bypass surgery, more than 80 percent of the patients showed similar severity and complexity of disease on admission, had no major complications, and achieved good clinical outcomes. The team did not find a single instance in which any one physician’s patients demonstrated higher levels of severity or complexity (“my patients are sicker”) than the patients of other physicians in the study.
In contrast, there was massive variation in physicians’ practices. Although use rates of particular treatment elements were consistent for individual physicians, they varied greatly across physicians. For instance, when the team examined individual treatment elements used for patients who were similar at hospital admission and achieved a good final outcome, it found that the highest physician-use rates were 1.6–5.6 times greater than the lowest rates. For each treatment, the hospital’s cost per case, not counting payments to physicians, showed about a twofold variation.
Despite deliberately choosing some of Intermountain’s highest-volume treatments and focusing on high-volume physicians, the study lacked sufficient statistical power to rank physicians accurately. It did not find any physician who was consistently a high or low utilizer across all of the elements tracked. Best patient care did not reside in any one physician. Every physician had something to learn, but also something to teach.
Finally, although the study could not accurately identify which physicians were providing optimal care, Intermountain could legitimately ask why physicians’ use rates were so different and what constituted best care.
Process Management
Accordingly, the findings forced Intermountain to focus on the processes of care delivery that underlie particular treatments, rather than on the clinicians who executed those processes—the “measurement for improvement” approach discussed (in the full article). As the inquiry continued, the system was eventually able to document significant declines in physician variation. Physicians led almost all of the changes themselves. Declines in variation were associated with large declines in costs, while clinical outcomes remained at their original high levels. For example, Intermountain’s average internal cost for performing a total hip replacement fell from more than $12,000 in 1987 to about $8,000 per case in 1989.
The Intermountain clinical quality, financial utilization, and hospital efficiency analyses led the system to process management theory. Quality improvement is the science of process management. W. Edwards Deming, the father of quality improvement, argued that every process always produces parallel physical, cost, and service outcomes. In medicine, clinical outcomes correspond to Deming’s physical outcomes. Cost outcomes represent the resources expended to create the clinical outcome, and service outcomes describe the interactions between a care provider and a patient as the process takes place.
Deming carried his analysis one step further, demonstrating that most process changes that produce better physical outcomes also cause costs to fall, and that in most cases, the best way to reduce cost is to improve quality. Deming’s insights gave Intermountain the tools it needed to take broad advantage of the quality-cost relationship in clinical and administrative services.
Full article – free download for the next two weeks only:
http://content.healthaffairs.org/content/early/2011/05/17/hlthaff.2011.0358.full
W. Edwards Deming (Wikipedia):
http://en.wikipedia.org/wiki/W._Edwards_Deming
Comment:
By Don McCanne, MD
This is what the accountable care organization (ACO) concept is all about. Intermountain Healthcare has confirmed W. Edwards Deming’s principle that “the best way to reduce cost is to improve quality.” Although ACOs have stumbled coming out of the gate (see qotd May 17 at pnhp.org), Intermountian has shown that we can achieve higher quality at lower cost without a cumbersome bureaucratic ACO construct.
Of particular importance is that the focus was placed on the processes of care delivery rather than on the clinicians who executed those processes. This opened up great possibilities for reform without the physicians feeling as if they were tiptoeing through a minefield of punishment and reward. The goal was purely better quality care for patients, and the savings to the system ensued almost automatically.
The full Health Affairs article can be downloaded for free during the next two weeks. I would strongly recommend doing so. It would also be worth your time to review W. Edwards Deming’s concepts, including his fourteen key principles, available at the Wikipedia link above. Both of these resources can help to readjust our mindset to meet the challenges of health care reform that still lie ahead.
What does this have to do with single payer? An automated financing system for health care would allow us to set aside our concerns about payment while we concentrate on quality processes for our patients. Everybody comes out ahead.