CONSISTENTLY DELIVERING VALUE
Value in health care is defined as quality divided by costs.1 In 2020, health care spending in the United States reached the highest historical percentage of gross domestic product at nearly 20%.2 It is clear that health services are no longer affordable under the current fee-for-service payment model. Payors are increasingly awarding contracts to providers who can consistently deliver value.
Intermountain Healthcare's vision is to "be a model health system by providing extraordinary care and superior service at an affordable cost."3 Its Clinical Programs are multidisciplinary teams charged with reducing unnecessary variation by standardizing clinical care across the organization according to evidence-based best practices to improve patient outcomes and decrease costs. Last year, Intermountain's Surgical Specialties & Digestive Health Clinical Program developed and implemented a new initiative, the High-Value Provider Network, as part of the broader effort to maximize value for patients receiving care within Intermountain.
HIGH-VALUE NETWORK AND QUALITY MANAGEMENT
A High-Value Network is a group of providers identified by the Surgical Specialties & Digestive Health Clinical Program as delivering high-value care. Providers may be either employed by the Intermountain Medical Group or affiliated clinicians in private practice. High-value providers are identified using an array of value-based metrics encompassing clinical outcomes, patient experience, and costs. Primary care providers can direct patients to designated high-value providers to ensure quality and minimize costs for the patient.
The High-Value Network serves as an auditing and feedback mechanism within Intermountain's overarching quality management system.4 Referral preference is a traditional economic incentive to encourage providers to adhere to evidence-based best practices. Eventually, assessments of provider performance may be made public. This will further encourage performance improvement, based on insights from behavioral economics that suggest individual behavior is influenced by perception of relative social ranking.5 Providers who desire to improve their performance receive support in the form of continuing medical education and mentoring.
HIGH-VALUE NETWORK DEVELOPMENT
The Surgical Specialties & Digestive Health Clinical Program oversaw the development of the High-Value Network for 7 surgical and gastrointestinal subspecialties. Associate Medical Directors and administrative leaders for each subspecialty worked with frontline providers and a team of data analysts to define metrics, collect data, and generate individual provider scorecards. Teams defined metrics based on Intermountain's Fundamentals of Exceptional Care: quality, safety, access, experience, equity, stewardship, and caregiver engagement.3 Analysts queried data for calculating metrics from Intermountain's enterprise data warehouse. Teams combined metrics using a point system to create performance scorecards. Predefined point thresholds determined high-value status. Subspecialty leadership teams email scorecards to providers each quarter. Primary care providers can see High-Value Network status when referring patients for surgical and gastrointestinal specialty care using the eReferral application within Intermountain's electronic medical record.
MEASURING VALUE
The Surgical Specialties and Digestive Health Clinical Program plans to evaluate the success of the High-Value Network based on adherence to evidence-based care processes and clinical, service, and cost outcomes. For example, the Clinical Program has created a Care Process Model for prevention of surgical site infection in patients undergoing colorectal surgery. The Care Process Model is a bundle of evidence-based interventions shown to reduce the incidence of wound infections.6 Adherence to this Care Process Model is one of many measures included in the High-Value Network scorecard for general surgeons. Surgical site infection rates at the individual provider, facility, and system level are tracked using a web-based dashboard application with transparency, and leaders periodically review trends with frontline teams. Additional quality outcome measures include unplanned post-operative visits to the emergency department and hospital readmissions. Safety measures include appropriate peri-operative utilization of opioids and antibiotics.
LESSONS LEARNED
Associate Medical Directors and administrative leaders found development and implementation of the High-Value Network challenging. The lack of an established framework for generating value-based metrics made it difficult to create measures that were relevant and reliable. Integration of a previously validated approach for creating procedure-based quality metrics was helpful.7 Collaboration with frontline providers during this stage was crucial to ensure potential measures were acceptable and meaningful to patients and clinicians. Surgeons showed enthusiasm for using validated patient-reported outcome measures to evaluate quality. However, integration of these measures was difficult in the absence of a data collection system for tracking patient-reported outcomes longitudinally.
Another challenge leaders faced was striking a balance between process and outcome measures. There are tradeoffs. From a patient perspective, value is determined by results and patients' perceptions of those results. However, many factors influence patients' subjective interpretations of outcomes, including many over which providers have little or no control. Providers only wished to be held accountable for activities over which they had full control.
Finally, providers acknowledged that value is a function of cost, but most were reluctant to fully embrace transparent cost data as a fair and meaningful metric. They felt many of the costs for subspecialty care were beyond their individual control, and some felt considering cost would compromise the quality of care.
NEXT STEPS
Intermountain's Surgical Specialties & Digestive Health Clinical Program developed and implemented a High-Value Provider Network to maximize value for patients and drive continuous improvement. This is a dynamic process, and lessons learned will contribute to the evolution of this initiative. Leaders are establishing a systematic approach for developing value-based metrics grounded in condition-specific pathways. Analysts are finding ways to adjust for patient factors to allow full incorporation of outcomes metrics, the true measure of value from the patient perspective.
A MODEL FOR THE FUTURE
SelectHealth, Intermountain's insurance company, has adopted a population-based payment structure for primary care. Eventually, this population-based payment model will expand to include specialty-based care. This will further align the incentives of surgeons with our desire to help people live the healthiest lives possible. Under this integrated model, condition-based pathways must extend beyond the peri-operative period and encompass the entire spectrum of care. Leaders will need to adapt the measurement system to include multidisciplinary care coordination and longitudinal collection of patient-reported outcomes.
Measuring and reducing episode-based costs for surgical care, while important, has limitations. Perhaps the most significant cost-saving value for specialty surgical care may be determining when patients will benefit from equally effective and less expensive nonsurgical treatments. Identifying measures that improve appropriateness for surgical intervention will be crucial. This will be a new paradigm as the historical fee-for-service model rewards surgeons who operate. Surgeons must support the transition to value-based payment, and reimbursement should not penalize surgeons who recommend nonoperative interventions. Finally, there must be more transparency in the costs associated with procedures, so consumers can have a clear sense of the value created by high-quality care. As value-based scorecards for an integrated healthcare delivery system become available to the public, patients will be able to make more informed decisions regarding their care and ideally decide based on value.
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