8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 1/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 2/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 3/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 4/64
4
V a l ui n g H e a l t h C a r e : I m p r o v i n g P r o d u c t i v i t y a n d Q u a l i t y
rom some angles dierent than those typically ound
in reports or studies in this policy area.
This report represents the distillation o thecollective wisdom o the Task Force members. They
were not asked to support every suggestion or idea
put orth here or to approve the precise wording o
this entire report; requiring unanimity would have
ruled out too many good ideas. Instead, we present
here a “sense o the room” as to which approaches
hold the most promise (and which are overrated) and
what the basic choices are. Despite our multiplicity o
perspectives, we ound many points o intersection.We canvassed what we call the adjacent
possible—that is, incremental, but important,
workable reorms that should improve the productivity
o health care and its value independent o whether
and how the recently enacted Aordable Care Act
o 2010 is ultimately implemented.2 We did not seek
giant, dramatic steps; we avoided sweeping claims
and rejected purported magic bullets. We believe
that a quest or sweeping, comprehensive, one-shotreorm is problematic because it misconceives the
health care system as an engineered “system” rather
than a natural ecosystem, perhaps as intricate and
complex as anything to be ound in nature.
Instead, we ocus primarily on incremental
changes which, taken together, can cumulate to
signifcantly advance both productivity o health
care and its outcomes. These reorms build on or
accelerate changes whose implementation runs with,not against, the grain o the health system’s existing
stakeholders and structures. We thus sought to avoid
measures requiring massive new expenditures. Some
o the regulatory or structural changes we recommend
would gore established interests’ oxen. But they havein common the virtue that, as the saying goes, you
can get there rom here.
Finally, we have chosen measures or their
exemplary value, as well as or their intrinsic
merits. They point toward a promising general
strategy: releasing and putting to work resources
that, or whatever reason, the current system has
locked up. Japanese automakers’ leap orward in
productivity came, in the main, not rom technologicalbreakthroughs unavailable to Detroit or rom
out-investing Detroit, but rom better use o existing
resources: reeing up the knowledge o assembly-line
workers, implementing real-time quality controls,
reorganizing and streamlining supply chains, and
putting the customer at the center o the system.
In that sense, the Japanese automakers unlocked a
leaner, more productive, more modern orm within
the confnes o an older system.In much the same way, we propose the
“jail-breaking” o health care. Our health care
system is rie with opportunities to improve
productivity by using existing resources better—
resources that include not just money, but the talent,
organizational skill, and knowledge o practitioners,
providers, researchers, and (especially, in our view)
patients. Much as the cheapest and oten astest
source o new energy is the more efcient use o oldenergy, so the cheapest and astest road to a more
productive health system is to put untapped value
to work.
2 We borrow the term “adjacent possible” rom Steven Johnson, who coined it. See Steven Johnson. Where Good Ideas Come From: A History of Innovation (Riverhead Trade, 2011, reprint edition).
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 5/64
Localism is another common thread running
through many o our suggestions. Although
cross-cutting changes to policy or regulationsometimes are needed, too much time and energy are
ocused on top-down, Washington-directed reorms.
This is true especially now, as the new Aordable Care
Act (ACA) eectively has exhausted, or the time
being, the country’s capacity or sweeping change
at the ederal level. Particularly while the ACA is being
digested, implemented, and perhaps modied, most
eective change will be locally designed or adapted to
local conditions, oten varying rom region to region,provider to provider, and even patient to patient.
What we can generalize, however, are changes
in incentives that help identiy and propagate
productivity improvements. Much as a hydrologist
uses general principles o geology and fuid
dynamics to understand where to build or to remove
dams or levees to change fows through a larger
system, so understanding and using incentives
better can point the way toward health productivityimprovements tailored to particular regions, providers,
and patient populations.
By design, we have brought together a varied
assortment o ideas and suggestions, illustrating the
messy, grab-bag nature that eective changes oten
need to take. Yet our proposals do all (albeit with
some overlap) into our broad categories, which
structure the recommendations section o this report.
Our specic policy recommendations are summarizedin the table at the end o this Introduction.
n Harnessing information: how systematically
gathering and sharing data can unlock knowledge
that produces systematically better choices. Thekey here is to incentivize a new corps o data
entrepreneurs to collect and analyze existing
medical data to discover and then disseminate
the use o new therapies.
n Improving research: encouraging more
collaboration across institutions and unding more
translational research (aimed at “translating” basic
scientic discoveries into medicines and therapies).
n Legal and regulatory reform: modernizing
medical malpractice systems, removing
counter-productive restrictions on health insurance
premiums, and streamlining new drug approvals.
n Empowering patients: there are large
benets o giving more power to the people
who matter most—patients—to make inormed
decisions about their own care.
The ideas here are not new, though many o
them are amiliar only to the cognoscenti. To the
contrary, we have sought ideas that have showed
promise in the eld, and then attempted to set them
in a context that exploits the adjacent possible.
I this report can ocus more minds in the health
policy community and general public on nding and
implementing those changes, in everything rom
clinical practices to regulatory structures, it willhave succeeded.
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 6/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 7/64
Lie certifcate Birth and death certifcatesalready exist. The “liecertifcate” is a bundleo standardized healthinormation that would
travel with consumers andaccumulate as they passthrough health-relatedgateways: vaccinations,procedures, medications,
amily history, and so on.
The ederal government should undresearch and development o the liecertifcate concept.
PolicyRecommendation
DeploymentDescription
reseach recommendations
Teams or research
Encouraging translationalresearch
Break down the isolationo researchers andencourage collaborative,crosscutting researchby creating teams oresearchers rom across
multiple institutions.
Eorts to encouragetranslational eorts, suchas the National Center orAdvancing TranslationalSciences at NIH, should
be strengthened andaccelerated.
The National Institutes o Health couldcondition a portion o its R01 and othergrants on being awarded to teams oresearchers, with larger average grantsmade available to larger teams.
Translational research should be viewedas a discipline in its own right, supportedby unding models that encourageinterdisciplinary, applied research and
nourished by a stream o researchers
trained specifcally in college ortranslation.
PolicyRecommendation
DeploymentDescription
Data recommendations—continued
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 8/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 9/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 10/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 11/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 12/64
12
a recod of innovton
I the United States had accomplished
nothing else in the past hundred years, it would be
remembered in history or its extraordinary record omedical innovation. In a century o staggeringly
rapid improvements in medical knowledge and
technology throughout the West and Asia, the
United States towers over others. Odd though it
may seem, at the dawn o the twentieth century,
the United States was a medical backwater
relative to Europe; but the second hal o the century
saw a remarkable fowering o science, technology,
and innovation, supported and driven by the world’slargest economy and the world’s greatest scientic
and academic inrastructure. One might say, without
undue ear o exaggeration and despite the current
angst over health care cost and quality in the United
States, as the Italy o the High Renaissance is to art,
so America o the past sixty or so years has been to
medicine.
Benets rom these advances have been valued
in the trillions o dollars and have led to a consistentlyhigher quality o lie or people all over the world.
Quantity o lie has improved, too. Health care
advances have contributed—along with improvements
in living standards, saer workplaces and childhood
vaccinations—to an increase in lie expectancy at
birth, which or Americans rose rom orty-seven in
1900 to seventy-seven in 2000 (an astonishing gain
o 110 days per year or two days per week during the
twentieth century).
3
One reason or this remarkableimprovement is the dramatic drop in inant mortality
o more than 90 percent (coupled with the 99-plus
percent decline in maternal mortality) over the
century. In addition, the two decades rom 1930
through 1949 alone, a period including the Great
Depression, remarkably saw the introduction o
electrolyte therapy and use o antibiotics,
accompanied by a 52 percent drop in inant mortality.4
Chapter One
Contours of the problem
3 National Vital Statistics 59(1): 33–34, Table 12 (June 28, 2010).4 CDC, MMWR Report 48(38): 849–858 (October 1, 1999).
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 13/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 14/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 15/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 16/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 17/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 18/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 19/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 20/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 21/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 22/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 23/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 24/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 25/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 26/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 27/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 28/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 29/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 30/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 31/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 32/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 33/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 34/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 35/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 36/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 37/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 38/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 39/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 40/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 41/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 42/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 43/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 44/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 45/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 46/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 47/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 48/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 49/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 50/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 51/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 52/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 53/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 54/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 55/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 56/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 57/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 58/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 59/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 60/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 61/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 62/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 63/64
8/2/2019 Valuing Health Care: Improving Productivity and Quality
http://slidepdf.com/reader/full/valuing-health-care-improving-productivity-and-quality 64/64