Help us design a low-cost, high-quality health system for the future

Health care needs fixing. Rising costs are unsustainable and quality problems are pervasive. Even as the national health care policy debate rages on, we must identify new designs for care and payment to address the crisis. At IHI's 21st Annual National Forum on Quality Improvement in Health Care in Orlando, Florida (December 6-9, 2009), we will conduct a minicourse on this topic (“Better Care – Lower Cost”) and we need your help.

Building on lessons from the IHI Triple Aim initiative and other projects, this day-long session will explore a proposed design for a care system that serves a population of 500,000 people. The design will knit together known best-practice components and theoretically-grounded innovations not yet fully tested. Design targets will be presented, including clinical outcomes at least as good as the top decile of US health care systems, continually improving health status in the population, and per capita costs 10% below the current lowest cost decile of hospital service areas in the US, with equal access for all in the population. Participants will advance the proposed design with their critiques and suggestions.

As we develop this course, we want to hear from you. Over the next two months, this space will serve as an open forum and repository for new ideas, both tested and untested (though we’d love to hear as many tested ideas as possible). We will continue to update the blog with specific questions, provocations, and our own feedback on what you provide. We hope that we will discover models, designs, and ideas we never dreamed of. We are confident that the solutions to our current health care problems are out there, in your daily work. Please share with us and help us design a rational, low-cost, high-quality health care system for the future.

Thank you,

Don Berwick & Tom Nolan

Don Berwick, MD, MPP
President and CEO
Institute for Healthcare Improvement

Tom Nolan, PhD
Associates in Process Improvement
IHI Senior Fellow

Wednesday, September 16, 2009

To get things started, we ask that you respond to the following question:

In an average American community with 500,000 people, what three changes in the health care system (organizations, resources, personnel, etc.) would contribute most to simultaneously reducing the per capita costs of care and improving care outcomes and health status?


  1. Here are my thoughts, but I am interested to see how this evolves!
    1. Every individual has access to a primary care provider, customized to meet their needs. This "primary care provider" knows the patient, there is a relationship of trust. For many, this might be physician PCP and for others, other's might fill this role. For example, individuals with a chronic illness probably need a physician, nurse practitioner or physician's assistant; for a teenager it might be a school nurse or counselor; for another, a mental health counselor might serve in this role, for others, a home health nurse or social worker.
    2. All health care services function with excellent, timely access, are highly efficient and reliable and care coordination is paid for. Again, customized to meet needs, so the person with active heart failure might need a clinical nurse specialist, but a new mom might need a promotora or lay health provider.
    3. Information, verbal, written, other media, is crafted so that it is meaningful and useable by the patient and their family to support their health self-management and decision making.

  2. Here is more interesting input-exceptional caring makes a difference. See this article in Health Affairs about 4 "medical home home-runs":

  3. High performing health systems have a foundation of effective primary care. Effective primary care as defined by IOM/WHO: access, relationship, comprehensive services, care coordination.

    There is a striking correlation between these attributes and the 'exceptional caring characteristics' described by Milstein & Gilbertson in the Sept/Oct 09 Health Affairs article describing "Medical Home Runs."

    To answer your question, the three changes:

    1: Everyone has unfettered access to health care (NB: access to 'insurance' is not the same thing as access to health care and as currently structure is anything but unfettered.)

    2: Support the effective delivery of comprehensive primary care.

    2.a: Payment is uncoupled from volume of services and is aligned instead with quality & experience indicators.

    2.b: Provide adequate funding for the full scope of work of comprehensive primary care - potentially doubling the primary care 'spend' by 100% still results in 15% net savings according to Milstein & Gilbertson, others estimate even greater overall savings.

    2.c: Provide practice improvement support with cost and engagement threshold set to attract primary care practices - low cost continual learning through networked groups of PCPs.

    3: Refocus quality measurement on indicators of core attributes of effective primary care. As pointed out repeatedly by Barbara Starfield, bundles of 'guideline adherence' metrics are poorly linked with the desired outcomes of improved population health and affordable care. Focus on Milstein & Gilbertson's 'exceptional caring characteristics. This is remarkably consistent with John Wasson's patient experience measure set.

    My third point of refocusing measures on what really matters may be the most important in achieving the triple aim. Putting aside public health for the moment, the goals of population health improvement, improved experience of care and reduced costs of care are best achieved in settings with good primary care.

    Effective primary care achieves more for populations than disease management/case management and measurement of bundled of biometrics and guideline adherence.

    L Gordon Moore

  4. 1.Giving the appropriate, patient centered, evidence based care to all patients every time, would reduce costs and greatly improve care. Medical mistakes, ommisions and errors cost a lot to fix in our healthcare system.
    2. Home care or hospital care for the terminally ill that could be chosen instead of expensive hospital care.
    3. Sliding income scale deductible payments for medicare patients and equalizing the amount that self-pay and payors pay to get rid of cost shifting.

  5. Clifford Waldman MDOctober 6, 2009 at 1:22 PM

    Another aspect of an efficient and effective healthcare system is communications. Good communications between primary care physicians and the patient and their caregivers as well as good communications between all healthcare providers in order to coordinate the patient's care. Our current non-system lacks this communication and the related coordination of care. The ideal community will have a community-wide (and perhaps wider) information system that connects all of the parties.

  6. Three things:
    universal coverage
    health information technology solutions that really make for an efficient use of health information
    support for patient-centered medical home

    My whole state only has 660,000 people, though--I would imagine that much of health care occurs in cities less than 500,000.

  7. Mike Taigman

    Here are a couple of thoughts:

    1: Active health policy in the community. If there are more liquor stores than grocery stores in the economically challenged part of the community then dinner is a bag of chips and a soda. If people can't walk someplace to pick up an apple and a carton of milk it has impact on health.

    2. Much of the cost associated with chronic disease could be mitigated with better self-care. A grassroots community based system of peer health coaches trained to support friends and family could improve compliance and decrease complications related to poorly managed chronic disease. If you're my friend and you know I have asthma you'd ask me if I had my rescue inhaler in my pocket when you picked me up for school in the morning. If you know I have diabetes you might ask if I took my medication this morning and what I had for breakfast. A peer coaching curricula could be provided as part of high school health class.

  8. Based on excellent research done by others, here are my three recommendations:
    1. Train more primary care doctors. Well trained primary care physicians reduce costs while improving health. Specialists do not if there are too many of them. To increase the number of primary care physicians, the system must reward them for practicing effectively or physicians in training they will seek other opportunities, as occurs now. In the US, adding to the primary care physician workforce will mean adding family doctors.
    2. These primary care physicians will need to be well trained and will need to practice more comprehensive care than they do now. This will also require some remuneration model changes. Family physicians will need to be able to provide real, first contact, comprehensive care over time referring only those cases too rare for them to maintain competency or requiring procedural competency beyond their training. Referral will not mean "send and forget" as chronic care is best delivered by generalists.
    3. Specialists should be allowed to focus on their areas of expertise, not be required to see patients for chronic disease follow-up, which currently accounts for half of all visits to specialists in the US.

    William Melahn, MD
    VP, Medical Affairs and Physician Services
    St. Claire Regional Medical Center
    Morehead, Kentucky

  9. 1. Reward Performance via Incentive Based Revenue Streams to reward providers who deliver high quality
    2. Reward Preventative Care by the Individual so each person has a social responsibility to keep healthy
    3. Fully integrated timely health information to both the bedside, clinic office & the patient.

  10. As medical director of a 20,00 visits per year psychiatric emergency service (PES), I urge the inclusion of a mental health perspective.

    First of all, mental illness and poor mental health care correlate with high rates of medical co-morbidity and mortality.

    Second, emergency care is particularly expensive, and improvements that reduce unnecessary PES and Emergency Department (ED) work should significantly reduce the overall cost of health care.

    PES’s and ED’s are the mental health system’s safety net, seeing casualties of a fragmented and discontinuous mental health system. By definition, apart from the care of individuals surprised by tragedy or new mental illness, the amount of emergency mental health services provided will be inversely proportional to the effectiveness of present-day psychiatric intervention and prevention, as well as to the overall health of the health care system.

    Therefore, PES/ED activity is a bellwether indicator, and it should be made a key metric or benchmark of both institutional quality improvement and broader health care reform at the local and state level. This approach is beginning to meet with some success in Milwaukee, where a public-private work group is creating a number of interconnected initiatives to solve the problem of psychiatric patient boarding in ED’s and hospitals.

    Adapting from Dostoevsky, the degree of compassion and scientific rigor in a health care system can be judged by entering its psychiatric emergency services. As long as mental health continues to be marginalized, there will always be a centripetal force driving difficult cases toward expensive and inefficient emergency settings.

    Jon Berlin MD

  11. Professor Helen Snooks, Swansea, UKOctober 16, 2009 at 5:05 PM

    Appropriate access, triage and care when possible in the community will reduce unnecessary emergency calls to the ambulance which frequently result in emergency department attendances and often emergency admissions to hospital. This default often happens simply because the professionals at each stage do not have a choice of providers to refer to, and do not have access to the patients records. However, alternative models need to be tested through rigorous research - preferably randomised trials so that costs and impacts for patients and the health system are identified and quantified.

  12. Where to begin such a vast topic - I will start with the development of Patient Information leaflets and the development of Integrated Care Pathways / protocols (ICP) [this can be achieved in surgical and medical areas].

    Huge costs are spent on developing patient information, but this cannot be quantified (£/$'s) in many areas; the content and costs are variable, information is duplicated, and on occasion can be inaccurate. I do not underestimate the work involved in streamlining this information across 'centres', [having started the process for cataract patient leaflets in ophthalmology] but this can be achieved.
    The prevention of duplication will result in reduced costs (of development and printed media as there will be economies of scale) and higher quality (consensus of professionals].

    There is a need to use a system to monitor the development, content and up-dates of leaflets and embrace the electronic age allowing patients to access them in various formats online (visually impaired/ different languages). [I believe such systems do exist, but it does require investment]. This will provide consistency to the information provided and ensure the patient is informed about risks, it will also support health record keeping where it can be stated that xxx patient leaflet was provided to the patient on yy date, and they had the opportunity to read it.. (consent forms should then refer to the leaflet; ideally contained in an ICP! - it would need to be sold correctly to those involved)). If patient information leaflets are held on an electronic system, old versions can then be retained as an archived copies and provided if such information is required for legal reasons in the future. This has to be built into the process of patient consultation ensuring patients are given information in a timously manner. While inital investment in such a system might appear large, it will undoubtedly lower the cost (one patient leaflet provided at the correct time, empowering the patient to access up-dates) thus increasing the perceived (and actual) quality of the health system for the the patient and also the provision of a consensus opinion by professionals will also streamline your patient pathway as a result of this process.

  13. PH Nilsson MD Dept of Internal Medicine, Växjö, SwedenOctober 18, 2009 at 6:50 AM

    Based on the ongoing work in my Dept of Internal Medicine I find teamwork in microsystems in care for patients with chronic disease extremely appropiate and efficient. As an example we have been able to reduce emergency dialysis starts i a group of uremic patients to zero. Everybody the last year has started ambulatory with a well functioning AV-fistula or a PD-catheter in place.We have a list of every patient with a S-kreatinin above 200 in the region. 4 nurses follow the patients between the doctors visits. Mutual rounds follow up the patients GFR, dialysisstart prognosis, transplant possibilities an so on. Nowdays more patients starts in PD, we have free resourses in the HD wards an so on. Nurses from the dialysis ward see the patients in uremisschool and on regular visits for follow up as predialysispatients.

    Another focus is to develop expert patients by education. This give the patient control of their own disease follow up. In the not far future I hope to provide the patients with their own medical records giving them the opportunity to follow tests eg HbA1c if diabetic och bloodcount if on bonemarrow suppressive treatmenst like methotrexate for reumatic-disease and so on. It will increase patient safety and provide time for the teams that care for the patients to meet up with immediate service when required.

    In summary:

    For groups of patients with chronic disease provide education and stimulate development of expert patients and create a devoted microsystem that follow up the patients in a way that emergency treatment is reduced. This results in better economy and happier patients!


  14. There are two scenarios A– with no system change (which risks tinkering with a fatally flawed system) and B – with system change. However A could also proceed whilst the system change in B is planned.

    A List- If there is no system change
    1. An electronic health record with increasing functionality to allow a paperless integrated health care record with prompting, decision support and administration software.
    2. Physicians record NNT and NNH for each of their clinical interventions. Both Physicians and patients need to learn to understand risks and benefits. Currently neither group understands risk, and different physicians and patients cope very differently with managing the same perceived risk. Physicians rarely use (and never record) NNT or NNH in their decision making with patients. Ideally the electronic health record would calculate up to date NNT and NNH for each patient for any change in management.
    3. Effective incentives for physicians to change their behaviour. This is a rolling programme of effective incentives (financial or otherwise) for physicians to undertake the proritised desired change in performance (e.g. 1 & 2 above). Incentives are not static but roll on to different behaviours and change on a regular basis to reflect the priorities of the day and to improve effectiveness of the incentives.

    B List – If system change is possible
    1. All the population has equal access to the state’s comprehensive health care system. This means a system that is free to users at the point of delivery. A private health care system will always be available in addition for those that want it.
    2. All the population is registered with a named provider of primary medical care. This means every patient knows who to go to for his/her primary care. The provider of primary medical care is a gatekeeper and has the skills and knowledge to provide the initial and continuing care of common conditions for all sexes and age groups. In additions he/she has local knowledge about the needs of population and patients and the options and resources available. This might be a GP or Family Doctor but it could include any suitably qualified person. This gatekeeper controls access to the wizards of the sub specialties in secondary care. Patients cannot consult a wizard without first approaching the gatekeeper.
    3. The primary care provider is responsible for his/her defined patient list/panel, and is the default case manager for each patient on that list/panel. Every GP (or other provider) knows for which patients he or she is responsible. Ideally primary care providers are resourced appropriate to the needs of the population they serve; there is an easy to use feedback process for all users to report on their experience of care; all health care commissioners and providers have regular performance management by peers and patients to ensure they are competent in their role and their management is optimal and consistent with peers, evidence based medicine or management.

  15. Salma Al-Khani, RPh, MHHA.
    Riyadh, Saudi Arabia

    As we all know, beter utilization of Primary care services and home based medical care when possible is known to be effective in beter care with lower cost my suggestion as follow:
    1- focuse on primary care centers quality of care possibly by conducting un annouced visits to the centers to evaluate level of care
    2- intorducing a primary care specific accreditation agencies that shall be mandatory on almost all available primary to assure minimum acceptable level of care and patient safety
    3- ensure the availability of the required medications and supplies in these promary care centers, to increase the patients trust for these centers
    4- beter utilize the media for the health awareness for the prevenatble diseases to increase public awareness
    5- make the Primary care centers an obligatory access to any other health care facility (Gate Keepers)
    6- when safe and applicable provide health care at home to minimize cost and decrease hospital related diseases and infections
    7- perform a focused public health awareness forums and discussion sessions with the public for example (Diabetis awarenss months, Obesity wareness months...)
    8- stress on the role of patients on his own safety and wellbeing
    9- alwayes consider providing beter care qulaity, will increase cost in the begining then cost will drop down dramatically

  16. All European systems have a few things in commmon
    1. Universal coverage funded by taxpayer or social insurance - this actually reduces costs because the risk is shared between the young and healthy and the old and sick.
    2. Comprehensive primary care system with family practitioners who are responsible for a registered population
    3. Incentivies for primary care to do as much testing and services in the community as possible

    Andrew Archibald

  17. I will mention only one change: Make sure that general practitioners become true Gate Keepers to specialized health care.

    This has many advantages. Two most important ones:
    1. More added value per euro for the patient because of task differentiation: a GP treats the flu, provides palliative care at home and a specialist treats the rarer diseases or diseases which need more specialized diagnostics or treatment. High volume less complex health care stays out of hospitals so you are not tempted to do all kind of CTs and ICU admissions which will not add any value to these patient.
    2. Much higher precision rate of diagnostics: when a gate keeper selects the cases which need to be referred to hospitals for further diagnostics, the chance a patient has a certain condition raises. This will increase the true positive and true negative test results and thus increase the positive and negative predictive value. This leads to much lower costs for diagnostics and much lower costs for treating patients with falls positive test outcomes.

    This works! For examples travel to the Netherlands. The number of CTs and MRIs is much lower. And also the prescription rate of antibiotics. This leeds to a methycillin resistance in S. Aureus of less then 1% compared to >50% in the USA.

  18. Jane.Hayward@suht.swest.nhs.ukOctober 19, 2009 at 8:39 AM

    The best health systems would take a best practice or model in the world and replicate this rather than leaving system design and decisions on clinical practice to the individual - 'best' would need to be judged on clinical outcomes and cost and needs to be at a disease/diagnosis level i.e. who treats COPD the best way in the world - lets do it their way

    Medical Technology and IT must drive healthcare in the 21st century in the same way it influences every other sphere of our lives in the developed and now developing world. In the UK we are miles behind other industries that have completely changed their service models to use IT to its full extent.

    Across 500,000 people one person should be in charge who can set a clear direction - this would be the most important change

  19. Have more primary care clinics available to patients. Have primary care clinic employees (from the Dr. to the receptionist) paid salary, whether they're providing treatment or educating patients on how to manage their own care. However, having such a narrow focus doesn't control things like the costs of drugs/devices...

  20. The proposed town of 500,000 would have appox. 20 EMS units to provide healthcare for citizens in distress. I would propose an equal number of public primary care facilities to provide basic healthcare for citizens. These facilities would be coupled with the EMS Centers or Fire Stations to create Health and Safety Centers. The "off-call" EMS providers could assist in the delivery of primary care at these centers.
    Each citizen would be required to have healthcare coverage either through universal insurance or a public/private mix. The citizens of this town would be provided with insurance discounts for maintaining a schedule of annual visits to the Health and Safety Centers for primary care and optional screenings.
    "Well Care" is to be viewed as a public service or a "Health Utility".

  21. 1. Drive out unnecessary cost to become more efficient and cost effective

    Unlike retail, hospitals don’t lose patients because they charge too much so they may not be motivated to be as cost effective as possible while achieving the positive clinical outcomes they rightly insist upon until their margins become unsustainable. Then there is often insufficient knowledge of how to efficiently and effectively find and remove waste, inefficiency and unnecessary cost.

    Let’s ask every professional certification organization and healthcare facility to teach and require proficiency in the skills necessary to continuously evaluate clinical and business processes to insure we are practicing evidence based care and performing our business processes efficiently and cost effectively. Let’s transparently share our knowledge and successes with one another for the benefit of everyone.

    Let’s assure executive level support for an environment of continuous process improvement with quantifiable goals and continuous monitoring of progress toward these target values.

    2. Specifically look for supply chain improvements to deliver value directly to the bottom line

    While labor can account for as much as 50% of total operating costs, the cost of materials management and supplies can exceed 35% of operating costs and is the second largest expenditure for a provider facility. Every dollar of supply chain savings goes directly to the bottom line.

    Let’s insist that materials managers implement no less than proven industry standard techniques, that they stay current of leading practices, assist with materials management in every department, including surgery and cardiac catheterization and establish and continuously strive toward achieving quantifiable cost savings targets.

    3. Institute an effective, multidisciplinary Value Analysis committee with clearly defined and reproducible processes.

    Let’s implement an effective multidisciplinary value analysis committee with representation from materials management, infection control, clinical education, finance, safety, risk management, reimbursement and physicians and clinicians to assure that products are functionally appropriate, cost effective and contribute to positive clinical outcomes prior to purchase and use. Let’s enable the committee as the gatekeeper with the authority to review every newly purchased item and to retrospectively begin analyzing the most expensive DRG’s and working down the list for opportunities to remove cost and to assure that expenses don’t exceed reimbursement.

  22. What we have learned from the health reform debate the in the U.S. is that the thoughtful and necessary changes proposed by the kind of folks who post to this site cannot and will not happen without the political neutralization of the many physicians and others who regard these changes as meddling with necessary autonomy.

    In a community of a half-million, health care costs cannot be contained and health status improved unless the public is brought into the discussion and recalcitrant docs don't have the dominant voice. Obesity is not just a "personal choice" -- though it is partly that -- it is linked to socio-economic status. The primary care physician as gatekeeper is not just cost control -- though it is partly that -- it is better care. And so on.

    The lesson of health care reform is that we must get beyond technical fixes and learn to fight for those fixes in the marketplace of public opinion. That opinion is often shaped not merely by "special interests" but by good, smart, hard-working docs who don't share the reformist values of this group. Either convert 'em or defeat 'em, but ignoring them has not worked, because the economic special interests use them to push their own agendas.

  23. Seems to me that the first matter to address, when trying to pave new ways to reduced costs and improved quality of service, is to establish which clinical services achieve demonstrable and lasting improvements in service user's health status, than study the parameters that make these achivements possible and then develop innovative healthcare delivery according to this evidence base. In practice I expect this will not be a popular approach and may even be politically unacceptable. But I miss not hearing the voices that dare speak of services that might, with good reason, be phased out because they add little or no value to quality of life. Focusing on what we do well will probably prove effective and efficient. We also need to temper service user expectations of what healthcare can deliver.

  24. • Replace medical malpractice litigation with no-fault compensation for treatment injury

    • Recognise the value of preventative and public health services: There is clear evidence that preventative and public health spending can help reduce future health costs and improve a country’s economic performance. This evidence is prominent in the areas of tobacco control, exercise and nutrition, immunisation, drinking water, and sanitation. Ministry of Health studies estimate that four out of the six year gain in life expectancy of the New Zealand population from 1981 to 2004 can be attributed to prevention (and the remaining two years to treatment). For example, approximately 80% of the reduction in coronary disease mortality over this period can be attributed to shifts in the population’s risk factor distribution (resulting from primary and secondary prevention). We support the notion that all interventions - preventive and therapeutic - be assessed for cost effectiveness, so as to optimise the mix of publicly funded interventions.

    • Consider the broader determinants of health Taking obesity as one example, we currently live in an obesogenic environment where high fat, energy-dense foods are cheaper than healthier (e.g. fruit and vegetable) food options, where schools are permitted to sell unhealthy foods to young children, where foods high in saturated fat and sugar are widely advertised to vulnerable populations, and many people are unable to safely walk or cycle to work or school. Given these types of competing forces, healthcare alone is unlikely to succeed. We must consider the broader determinants of health.

    • Increase the use of cost-utility analyses in prioritising interventions as a matter of urgency We would also encourage the use of cost-utility analyses to compare public health interventions against acute clinical interventions, and to compare the expansion of existing proven interventions against new interventions. For example, Pharmac’s One Heart Many Lives campaign to increase the use of statins among people with high risk of heart disease (particularly Maori and Pacific Island men) costs under $8,000 per quality adjusted life year, providing much greater value for money than many new medications and technologies currently being funded with a lesser degree of scrutiny. If we are to improve our population health status then one of the most fertile areas is to ensure that those who are in need really do access appropriate care when that care is known to be cost-effective. That is, a good way to maximise population health gains for any given spend is to increase uptake of cost effective treatments when there are disparities in access - where disparities indicate that some groups have great potential to reach the levels of access (and consequent health gains) that others have already achieved.

    I hope this helps.

    Dr Marie Bismark
    Senior Associate
    Buddle Findlay

  25. Secondary Gain.

    What is the secondary gain in the problem?
    90% - focus on solution thinking - 10% on the problem.

    Who does health best? Studying the optimally healthy - shifting the thinking ... Not just the best hospitals -- studying those long-liver-s who do it best ... SUPERCENTENARIANS
    and for those who love the data (scroll down for it):

    Then, apply that to the countries where they are from, drill it down to the hospitals, the surgeons or lack thereof ... and we could be on to something.

    Joanne Zaborowski
    Quality, AHS

  26. 1. Make the 500k responsible for paying for their own healthcare (may need to make that groups of 300k to 3 million and define geographic and political entities like cities, counties, or states). Tax transfer from federal government to fund.
    2. Get employers completely out of the healthcare loop.
    3. Transparent reporting of health care process and outcomes (by 300k groups) coordinated at the national level.

  27. Run a 100% clean system.
    Deliver a 100% clean product.
    Tell the absolute truth always.
    Respect informed consent and patient's right to self-determination.

    Creating and maintaining corruption is very costly and in the end gains the system nothing better than could be gotten by just doing the right thing--always--and dealing with problems that arise truthfully, ethically, and with clean hands.

    No more x-ray and records tampering.
    No more lack of informed consent.
    No more patient abuse.
    No more lying.
    No more cover-up.
    No more...just stop cold. Just stop.

    The corrupting influence of lawyers and insurance companies need to be removed completely from the doctor-patient relationship; we need a direct, courtless/lawyerless patient-injury compensation/relief panel akin to what Finland has.
    The low-grade street-ethics and thug tactics now in place have to stop. We can do better than that.

    Elizabeth LaBozetta
    Central Ohio Patient's-rights Service.
    Citizens for Medical Safety

  28. So far all of these suggestions assume that all physicians are equally competent and equally well meaning and patients don’t need to know better. Does one orthopedic surgeon keep sending older women with shoulder pain into surgery, with no success, while another recognizes what frozen shoulder is and treats them with physical therapy and has a 100% success rate? In the current system no one knows. No one even knows that the first surgeon has little or no success. Whether it is public or private, for profit or not for profit, surgeons create their own records and record that their operations are perfect as a matter of routine. That first surgeon’s operations might have been perfect, but they are of no benefit, and he continues to do them.

    If patients were crowd-sourcing that kind of information, the kind that health care professionals do not record, for the first time there would be data not only on that, but also on which physical therapists did a better job of healing frozen shoulder. Some physical therapy firms create schedules that extract all the money the insurance company will pay before treatment ends. Others require fewer days off work for the patient and fewer expenses for the insurance company.

    Nothing in scientific studies or evidence based medicine or best practices policies touches the fact that all providers are not equal. The very first step in making informed cost-benefit decisions about your health care is choosing providers based on more than rumors about beside manner. Patients can learn the kind of information they need only from other patients. No one else will record it. We need to plug patients in to helping each other by recording such information on the internet where everyone will have access to it.

    We need patients to be able to blog and twitter and Facebook about whatever happens to them in medicine without fearing repercussions, so that Google, or whomever, can make it available in a search. The surgeon operated on your shoulder and it did not improve? Then you went to another surgeon who sent you to physical therapy and now you are well? If you could have read about the dozens of other patients who had been there before you, you could have skipped the surgery and found a less expensive physical therapist than the one you went to.

    Without access to that kind of information, patients will continue to be hapless pawns with no choice but to do what they are told and pay what they are told while costs escalate and quality does not.

  29. Medical peer review for questionable patient care that is equally fair to both doctor and patient.

    I can provide a complete system of medical peer review that goes far beyond anything previously imagined and will function in every hospital in any and/or every state.

    Problem is I can't find anyone confident enough to test my system against currently existing systems of questionable patient care review, which unfortunately has been historically limited to malpractice litigation.

    Effective medical peer review, properly functioning in every hospital in America, can provide the most rapid and complete improvement in the quality of health care and for lowering cost than any other single step.

    Effective medical peer review is far more attainable then the naysayers will have one believe.

  30. Aside from the need for the obvious features of a cohesive healthcare system such as electronic medical records, patient and family centered care, less intrusion by the insurers and others,I believe that the most essential ingredient of a safe and effective healthcare system is professional oversight of performance. After forty years in practice I remain astonished by the lack of communication between members of the health care team. The oversight that I am addressing cannot be optional. It must be mandatory and that can only occur in an Integrated Delivery System or with a single payor that pays only for safe , quality performance.

  31. Lori Nerbonne, RN, BSN, Co-founder NH Patient VoicesOctober 22, 2009 at 8:46 AM

    1. Publicly reported mortality, infection, complication rates by surgery and treatment-type. Leave the high risk surgeries to the larger centers with better outcomes. We have over-duplication of high risk treatments ---this only increases unnecessary utilization & puts peoples’ lives at risk. (see the Dartmouth Atlas Research and look at the Leapfrog and Healthgrades ratings for high risk surgery units versus low-volume….also look at their ICU care ratings)

    2. More oversight based on outcomes; shut down units with unacceptably high morality or complication rates. Many hospitals/MD's are choosing to ignore Medicare outcome data.

    3. The over-medicalization of maternity care: No one is doing anything about our out-of-control cesarean, induction, and late premature birth rates because it is just left up to each individual hospital. Hospitals leave it up to the docs, so there is no accountability. There is no excuse for cesarean birth rates of 30 - 50% and induction rates of 50 - 80%.

    Maternity patients look like ICU patients, they are attached to so many machines. Get back to more nurses/labor support at the bedside and we can take these hi-tech machines away. Professional doulas, midwives, & p.p. home visits would reduce costs and bring back a more normal, healthy birth process. To do this we need a change in the payment system -- right now hospitals & docs are rewarded financially for high-tech maternity care and midwives/doulas struggle to get paid.
    We also need oversight for adherence toevidence based guidelines. Look at how long it took OB’s to cut down on doing episiotomies (decades of research). Now the same thing is happening with epidurals, cesareans, & inductions; this is a problem created by ‘convenience obstetrical care’. What ever happened to the standard: “I can’t do surgery on you because surgery isn’t medically necessary.”? More and more, surgical deliveries & inductions are being done because they can be done between 9 and 5, & they bring in more money. Yet, the risks of these procedures are not being disclosed in any way shape or form. ‘ Informed consent’ needs a complete overhaul.

    4. Provide patient-compensation insurance for patients who are harmed by hospital care. We have workers comp, health, car, life, home, and long term care insurance but nothing for patients who are harmed from MRSA, medication errors, failure to rescue, or outright negligence or malpractice. They are expected to just go on and deal with the resulting complications, pay for future medical care on their own, and deal with missed employment, wages, etc.

    5. Require entries on all death certificates to be signed off by hospital administrators and the MD that would read: “Unless indicated in cause of death or in contributing factors, this death was in no way caused by a medical error or a healthcare associated infection.”
    Currently, death records are filled with erroneous, misleading causes of death because we are allowing the very people who are making deadly mistakes to certify the death record. We don’t have laws requiring disclosure of medical errors, so they are also not being disclosed on death certificates. This is wrong and perpetuates medical harm and compromises patient safety. It also misleads future generations of families about their medical histories and causes years of unresolved grief and pain to surviving family members who often learn of these mistakes/their cover-up only after obtaining the medical record.

    It is time that we lay everything on the table. We should have an independent investigation done anytime a patient dies unexpectedly—and the patients’ family should be involved in determining whether it was ‘unexpected’ or not.
    The proof of how harmful our healthcare system really is depends on accurate outcome data and death certificates. As Mr. Berwick says "we can't improve what we don't measure." This includes certified causes of death as well.

  32. I wrote this piece once after spending a week as a patient in a private hospital and another week in an NHS hospital. The big difference between them was something that cost nothing. Perhaps worth sharing!

    (Here is a link to the BMJ post:

    Trisha Greenhalgh
    Professor of Primary Health Care

    The Big Difference

    I recently spent five days in a private hospital, where I had a routine operation. A few days later, for reasons I won’t bore you with, I was admitted to an NHS hospital where I had another operation. This was hardly a randomised controlled trial, but it did make for some interesting comparisons.

    In terms of creature comforts, the private hospital won hands down. My room had a plush carpet, an en suite bathroom, and a wide screen TV with 24 channels (four of them in Arabic). I chose my meals from a leather bound menu (and had I wanted to, I could have washed them down with champagne and smoked a cigar afterwards).

    But otherwise, the differences were hard to spot. The beds were of identical make and model, with the same crisp white sheets (incidentally, mine were changed more often in the NHS). The ancillary staff were equally cheerful, bringing titbits of gossip from the outside world. Without exception, the nurses were all angels. The doctors were equally efficient, committed and highly skilled. The operating theatres were equally spotless and well equipped; the anaesthetic rooms equally scary. I threw up approximately the same amount in each recovery room.

    So apart from the frills, what was the big difference? I think it was this. In the private sector, no-one entered my room without requesting my permission, and they did so in such a way (“Is it OK to empty your bin?”; “Is it convenient to take your blood pressure now?”) that I really believed I could turn them down.

    In the NHS, where I was also in a room of my own, the door swung open six times an hour and staff breezed cheerily in and out as they collected equipment, checked my chart, or hunted down the SHO. The only person to knock on my door and wait for a reply before entering was my husband.

    Nothing dreadful resulted (I was only caught unawares on a bedpan once), and if I had not just come from a hospital with a different culture I’m sure I wouldn’t have noticed. But here’s the lesson I learnt. Being a patient – especially a bed-bound one – does nothing for your self-esteem. When people value your privacy, they make you feel valued as a person.

    I didn’t miss the telly, and I can handle drinking tea out of a cardboard cup. But a little respect for privacy – which, ironically, costs nothing – could put the NHS on a level footing with Harley St.

  33. Tremendous focus on medical homes, payment re-structuring and system re-design in these posts make my aspiration for the US community of 500,000 seem small. But sometimes the smallest thing tips the balance of the discussion in new directions. I would like the discussants to consider the novel concept that perhaps, everybody needs a nurse! A community of that size would have a small batallion of nurses and imagine if they were organized in districts of community service. Nurses are natural leaders in communities and oddly enough, folks never stop and worry if their problem or concern is "bad enough" to talk to a nurse about. How can we build on that natural resource as re-imagine healthy communities?

  34. Any health care reform must include ethical reform regarding how medical malpractice is handled. Today the standard response when a doctor is confronted with a patient who is a victim of his or any other doctor's medial injury is to completely deny the injury.

    The entire medical system is set up to assist the doctor in denying the patient a solution to their injury. This is entirely a business decision to maximize profit. The expense and risk is born entirely by the victim. The victim has no choice but to seek legal remedy. This is extremely expensive and stressful and for most victims is the last resort taken before the statute of limitations runs out.

    Unlike the AMA propaganda, lawyers who take medical malpractice on contingency are hard to find, and only for specific cases such as brain damage or wrong limb amputated.

    The vast majority of victims cannot afford legal help and are left to suffer with their injury, abandoned by the medical and legal professions. Insurance will not pay for repair unless a doctor agrees to disclose the injury, therefore victims are left to pay for any repair themselves.

    The financial strain of medical malpractice causes victims to lose homes, jobs, and eventually fall through the cracks of society while the offending doctor is left untouched.

    This has been about the survivors of medical malpractice. According to recent studies, about 195,000 deaths occur each year to preventable medical mistakes. The number of medical malpractice victims who survive is likely greater.

    Any reform must have the structure and law to enforce accountability to the victim.

  35. Simplify:
    The health care system is complicated and ineffectual for many due to the complexity of systems. The more we can have integrated systems, with clear communication pathways and simple communication handoffs, quality, access and satisfaction by the patient, family and providers will improve. Integration needs to include behavioral health, oral health, and others systems of care that have previously been handled as separate systems.

  36. NHS Yorkshire and Humber is leading a programme of work to accelerate the delivery of Healthy Ambitions called 'Delivering Healthy Ambitions - Better for Less.' Clear 'better for less' opportunities are being identified with short practical briefings for organisations detailing the evidence for action, the action to be taken and the bottom line impact that can be expected.
    The first 'better for less' opportunity is on electronic consultations.
    E consultations can dramatically reduce the cost of caring for patients with diabetes whilst providing a high quality and convenient service. Currently over 220,000 people are registered across Yorkshire and the Humber as having diabetes and the cost of caring for those pateints is likely to rise significantly from the 07/08 level of £100m.
    Traditionally patients with diabetes who require more than the standard advice are referred to secondary care for a consultant opinion. If, however,an electronic consultation could occur between primary and secondary care, it is anticipated that the patient will receive appropriate advice in a quicker and more convenient way for less cost. Based on prevalence studies, by 2014/15, expected savings in diabetes care across Yorkshire and the Humber from implementing e consultation, would be around £20m.
    Pilots around e consultation for diabetes have taken place at Airedale Hospital Trust and at Bradford Hospitals NHS Foundation Trust where use of e consultation resulted in a 50% reduction in outpatient appointments for the duration of the pilot. Associated cost and quality benefits from fewer patients making the journey to hospitals for followup care were evident.

  37. In BC, the concept of “better care, lower costs” is being addressed from a variety of fronts --- all aligned toward the common Triple Aim goals of improving population health, improving the patient and provider experience of care, and reducing per capita costs. One of the areas where BC has seen the largest overall system improvement is in the reduction of hospital utilization. This is being addressed through:
    • Reducing hospitalization rates for Ambulatory Care Sensitive Conditions;
    • Reducing hospital bed use by patients awaiting alternate levels of care
    • Improving attachment of patients to General Practitioners (GPs). Here's a link to our recent article on "increasing value for money" in Health Care Quarterly:

  38. This is a great conversation and the previous posts pose thought-provoking ideas. Improving patient outcomes and reducing costs do not have to be tradeoffs. The challenge: the health care system is fraught with waste that increases costs and places obstacles in the face of optimized care. One of the most important changes to the health care system that can both improve patient outcomes and reduce cost is to eliminate waste at all levels. Health care organizations of all sizes are adopting lean management strategies to find and eliminate waste in all they do. The results typically provide simultaneous improvements in access, safety, and cost.

    Cutting costs in traditional ways—slashing headcount and reducing services without eliminating waste—will adversely impact the quality of care. Hospital administrators and staff must be willing to make tough choices to restructure care pathways and the infrastructure that delivers care along value streams, with value as defined by our patients. This most certainly means learning new skills and realigning roles and responsibilities to fit new/redefined care pathways; combining current skills and becoming less specialty based in some case. As labor costs represent more than 70% of healthcare delivery costs, health care systems of all sizes would benefit by the creative, efficient ideas that are generated by a lean problem solving approach.

    For example, one progressive lean-thinking hospital system applied lean management to develop a new inpatient care process where nurses, pharmacists and physicians sit down with a patient and their care givers within the first 90 minutes of their visit to develop a single care plan. This collaborative care approach as resulted in a 25 percent reduction in total cost of care, eliminated medication errors for two consecutive years, and reduced patient length of stay by 16 percent while lowering re-admission rates.

    In a second example, one US hospital applied its lean expertise to an inventory reduction project, with an understanding of how inventory is a major waste that hides other more subtle wastes. With standard work and visual controls, they reduced par levels to a 30-day supply or less, developed a system for reordering triggered only by usage, and organized and consolidated their storage areas saving $383,868. Most importantly, the hospital reclaimed more than 1,800 staff hours – having exposed the waste of human talent their material replenishment system was hiding. Clinicians now spend less time searching for supplies and more time caring for patients.

    By using Lean principles and transforming our health care culture to pursue perfection in 4 True North improvement dimensions – human development, quality, service and cost (productivity) – health care systems will continue to achieve truly breakthrough performance results and patient outcomes for communities of all sizes.

    Marc Hafer
    Simpler Healthcare

  39. Maccabi Healthecare system in Israel provides medical care to 1.8 million members.
    the following issues can improve the medical care and reduce the cost:
    1) Good communication between all health caregivers such as primary care physicians (PCP) and specialists in order to coordinate the patient`s care provides efficient and effective healthcare system. This provides integrated information and prevents unnecessary and costly tests and examinations. Our Healthcare system provides a wide health information system that connects all inside caregivers integrated in a central electronic medical record. This solution really provides efficient high quality care and low cost.
    2) Tele-medicine technology can provide electronic consultation which reduces the the cost of caring for patients with chronic conditions (such as Diabetes). Traditionally, patients with such conditions are often referred to a specialist for a consultation. Low access, transportation difficulties and physical disabilities can prevent such important medical care. However, an electronic consultation using Tele-medicine technology provides valuable communication between the PCP (with or without the presence of his patient) on one side and the specialist on the other. Through providing such high quality care and a convenient service, it is anticipated that the patient and the PCP will receive appropriate advice in a quicker and more convenient way for less cost.
    3) PCPs are the mile-stones for providing good quality of care and they are the gatekeepers of medical cost. PCPs need to practice more comprehensive care than they do now. This requires a re-design of the primary care system provided. PCPs in our healthcare system work in their private clinics without any further assistance. Patients refer to PCP clinic on demand for urgent treatment and prescriptions provision. Comprehensive care must include care for the whole community: the healthy (health promotion and preventive medicine that was proved to be cost-effective) and the sick (patients with chronic conditions). Therefore, our healthcare system started a gradual re-design of the primary care system. The re-design includes the following keys: patient centered care, proactive and case finding approaches, one-stop shopping which is accomplished by a team work (in the clinic of the PCP) consisting of the PCP himself, a community nurse, a social worker, and a dietician who were chosen from the same community in order to adjust the healthcare provision according to the needs, traditions, and culture of the local community. In addition, an access to electronic information tools containing full information concerning the medical status of patients are provided to help the team to coordinate working plans.

  40. I think the fastest way to move everyone in the direction of widely testing and/or adopting efforts aimed at improving quality and reducing cost is through the creation of meaningful financial incentives. In my estimation, this is very aligned with the Triple Aim.

    In an era of scarce resources, most hospitals are reluctant to dedicate resources to test new quality initiatives when the savings just go back to the payor as unrealized cost (as is commonly the case). In my opinion, it would be better to allow hospitals to trial and validate tests of change that transform care in ways that demonstrate tangibly improved objectives (e.g., reduced length of stay, better clinical outcomes, reduced costs) that then result in shared savings with the payor. The introduction of new clinical processes born out of these innovative practices (and validated through the application of reliability science) - call it 'process-based evidence' if you want - could be very powerful and beneficial to all. It's also easier to make the business case / create the value proposition for the costs expended and the risk taken by the institution when improvements result in shared savings.

    Payors could also support demonstration projects with physician-hospital organizations where care is pre-paid for a community (at a reduced rate) and is benchmarked for the impact the effort has on community health. Any savings (assuming that benchmarks are met or exceeded) could be pocketed by the PHO/other providers and the improvement methodology could be spread to other areas in the country/world. (There may need to be some loosening of anti-trust regulation to allow collaborative efforts between providers of all types).

    Another way could be for healthcare premiums to be tied to BMI, blood pressure control, cholesterol level, smoking status, or other reflections of wellness. Savings could be pocketed by the individual or could perhaps be used for rebates for health club membership or for purchase of healthy foods.

  41. This is an excellent straightforward exercise!
    Reviewing your answers (critically) the most voted changes are:
    1. Primary care features change (13 times)
    2. Information systems (9 times)
    3. Evidence based care (5 times)

    In my opinion the major changes should occur in:
    1. The delivery system: toward an integrated care system
    2. The financing system: cost-effective financial incentives
    3. The information architecture: to interconnect all health agents (from patients, carers, doctors... to hospitals)

    Tino Martí
    Editor of the Journal of Health Innovation and Integrated Care

  42. The overuse of specialty care services leads to an increase in costs and in the end a decrease in patient care.

    Incentivizing primary care, so that more medical students are leaning away from specialities to pay off their medical school loans will decrease variation in the type of care patients are getting.

    This will improve care, decrease costs and affect the population as a whole.