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

Tuesday, October 27, 2009

For an average American community with 500,000 people, what new investments in health care and health status improvement would have the highest financial return on investment, while improving care and health, over a five-year period?


  1. I think this question is potentially very difficult to answer without knowing what our theoretical community already has! I will assume we're talking about the "normal" situation, so here are a couple of very specific ideas:

    1. Robust weight management programs! In the long run, obesity is an enormously expensive condition with complications including diabetes, heart disease, joint degeneration, and much more. Providing social pressure, financial incentives, and "the hard truth" are a step in the right direction. How about gym memberships that are free if you spend at least three hours a week there, but cost $5 for each hour you fall short? What if the doctor said "It looks like you've been gaining a little weight, you really need to nip that in the bud and get back to your healthy weight. Here are some suggestions for how you could do that."

    2. Sick leave. How many people currently work for a company that has gone to a plan where your vacation time and sick leave are combined? The result is that employees tend to come in when they're sick, rather than use that valuable vacation time. The effect is that the sick employee not only makes mistakes and does sub-standard work himself, he also spreads his germs to other employees and potentially to already sick patients!

  2. I’d suggest that an investment in the development of grassroots level chronic disease management self-care competencies and disease prevention. Building the capacity for patients, their friends and family to better manage asthma, diabetes, CHF, sickle cell, hypertension, etc. should decrease costs significantly over time. Investment in prevention activities like smoking cessation, elderly fall prevention, proper car seat usage, youth violence prevention, etc. should decrease overall healthcare costs. The ROI will come from cost savings.

  3. Smoking cessation
    Strict gun controls

  4. 1. Multidisciplinary team care and communication design.
    2. Care managers (primarily fact to face) who have easy access to and support from multiple disciplines.
    3. An integrated, user friendly, electronic medical record repository with tracking capabilitly and alerts for both care milestones and preventive visits.

  5. Ensuring that all members of the community have a primary care provider and receive preventative care. Not using the Emergency Department as a substitute for a primary care provider. Ensuring the members of the community have the resources such as transportation to appointments, money for co-pays, ability to get prescription drugs, understand the education behind their medical care, and not having language barriers.

  6. I think health care is only a right if individuals take personal responsibility for it. In that vain individuals need to all pay something for their care. A sliding scale based on income would be fine. Even if it is $5 per routine visit, a little more for ED visits. People need to think about and participate in what is best for them and having to allocate personal dollars works very well for most. When you do not have to pay you are entitled and believe you are owed something. When you have that perspective you have no personal responsibility for your health and rely on everyone else to pay for your poor decisions! Obviously there would need to be a system set up to deal with individuals who are unable to take personal responsibility due to intelligence or choice. This would be a minority of people. A high quality but no frills County Clinic/Hospital also used for teaching purposes would work well. This system would also be available to anyone who chose to join. Weight control, diet, exercise and smoking cessation all important components. Also differential costs for new technology/meds etc that have same benefits/outcomes. I.E. if you want a newer drug that has potentially a mildly improved side effect profile you would pay extra for it. Right now only the wealthy are forced to do that. Similar to above a sliding scale based on income. We need to have everyone make value decisions when purchasing health care. In Arizona our medicaid equivalent program AHCCESS-members can get meds, procedures etc much easier than individuals who pay for their care. They demand everything without value judgements. Individuals and families need to make value judgements about their care.

  7. 1. Improving our educational system- reading, writing, speaking-just the basics will, overtime, pay back big dividends toward improved health.

  8. Provide all patients 24/7 access to their own pre-populated record in a simple practical and user friendly format. Absent a fully populated PHR or EHR begin with a Continuity of Care Document (CCD) to include most recent labs, medications and current providers including case managers. Give patients the option to share their CCD with anyone. This would improve care coordination, engage patients and bridge medical and community providers in the service of patients.

    Consider David Kibbe's comments on The Health Care blog titled "Back to Basics: Toward a Core Set of Relevant and Portable Personal Health Information"