There is an old saying that every unsustainable trend, by definition, comes to an end.  The U.S. healthcare system has been on an unsustainable trajectory, consuming more and more of our national income while failing to deliver the kind of care that Americans need and deserve.  But although every unsustainable trend eventually ends, how it ends is up to us.  The healthcare system has the potential to collapse under its own weight, requiring Americans to pay even more for healthcare, forcing draconian and blunt cuts in the kinds of services available, and putting high quality healthcare out of reach for the poor and the sick.  An alternative future is one in which payers pay for value, providers become more efficient and patient centered, and consumers become increasingly engaged in caring for themselves.  In this future, healthcare becomes an important force for improving the health of the American public.  What will determine which path our healthcare system will take?  While the fate of our healthcare system will be influenced by policymakers in Washington DC and the state capitals, it will ultimately be decided by each of us – providers and patients who are involved in the daily work of delivering and engaging in healthcare.

The journal Healthcare: The Journal of Delivery Science and Innovation is an effort to nudge us toward a better, sustainable path for our healthcare system.  The mission of the journal is simple:  to play a meaningful role in fostering real change in the healthcare delivery system.  The journal wants to be a venue for sharing the best ideas for delivery science, payment innovation and smart use of health information technologies.  The journal was conceived by Amol Navathe and Sachin Jain, who have been thinking long and hard about compelling new approaches to bring about change in the healthcare system.  It took years of persistence to line up a terrific publisher, put together a top notch editorial board and recruit some of the nation’s best minds to lead individual theme areas.  And it paid off handsomely.  On June 21, 2013, Healthcare officially launches with its premier issue, and what an issue it is.

The two introductions are short, pithy and worth reading over and over again.  The first is by Don Berwick, the former Administrator of the Centers for Medicare and Medicaid Services but even more importantly (at least to me), the man who has done more to promote quality and safety than anyone in recent memory.  Don frames the issues in ways that only he can, reminding us that we can have the best healthcare system in the world – we have all the pieces – but we have to learn how to put it together.  The second introduction is by Jim Kim, the President of the World Bank.  Dr. Kim reminds us that while great ideas are common, great execution is priceless.  Yet, as he says, too often “we have an inexplicably high tolerance for poor execution”, which compromises the quality and efficiency with which care is delivered.  This kind of waste is no longer tolerable in the U.S. and is completely unaffordable elsewhere.

The rest of the journal is filled with ideas and research from some of the leading thinkers in the country.  Kevin Volpp and his colleagues describe their approach to refining the way randomized control trials are conducted to improve healthcare delivery.  Instead of taking years to carefully control every aspect of an evaluation in order to perfectly isolate the effect of a specific intervention (that was conceived ex ante), Volpp and colleagues offer a more flexible approach.  Borrowing ideas from operations research and focusing on the notion of iterative innovation, the authors lay out a path that will allow providers and researchers to understand and improve real-life interventions without compromising scientific rigor.  This is amazing work that could profoundly change the rate of innovation in healthcare delivery.

I want to highlight a few other pieces.  Clese Erikson from the Association of American Medical Colleges has a terrific piece about the much discussed but poorly understood “primary care shortage” and describes ways in which new models of care delivery can help improve the productivity of the current workforce.  More importantly, Clese takes on many of the arguments that people on both sides of this debate like to make (such as the potential role of health IT to make doctors more efficient) and calls for rigorous evaluations so we can have a more data-driven debate.  Mike Chernew has a critically important piece about global payments, a new way of paying for healthcare that has seen important early success.  Chernew points out that while such a payment approach is promising, its success and spread over the long run is by no means certain.

One of my favorite papers in this issue is by the prolific Zirui Song.  Song and colleagues (including Chernew) examine the best known global payment model, the Alternative Quality Contract, in Massachusetts to look carefully at utilization of technology-intensive medical services. They find that some services which are high value, such as colonoscopies, increased under the AQC while other services of more questionable value, such as angioplasties, fell.  This is exactly what we would hope to see.  It is a particularly important finding because it reveals that the underlying mechanism, is that savings were primarily achieved by a shift to lower priced providers.  Whether utilization of lower value services continues to decrease over time will be critical to watch.

Several more studies are worth highlighting.  An excellent study by Hao Yu (with Ateev Mehrotra and John Adams) examines the reliability of utilization measures for performance profiling primary care physicians (PCPs).  PCPs are being increasingly profiled by payers and labeled as “efficient” or “inefficient”.  Yu and colleagues examined 11 measures that are commonly used to profile physicians and found that 7 of them have poor reliability while the other 4 are reasonably good.  The implications are obvious and important:  if we use unreliable measures of utilization, we will imprecisely label doctors as efficient or inefficient, making profiling efforts useless or even harmful.  If payers and policymakers can use important empirical work like this, they are far more likely to be effective in their efforts to drive efficiency through physician profiling.

Tara Lagu (with Peter Lindenauer as the senior author) examines variations in spending on sepsis patients.  These are among the most expensive patients in the healthcare system, with the average case costing more than $20,000.  Lagu and colleagues find that while much of the variation in spending across hospitals is due to factors not easily amenable to intervention (e.g., severity of illness of the patient), one-third of the variation in spending is due to variations in practice style.  Given how much we spend on sepsis each year (over $24 billion), reducing even a small part of the variation can lead to substantial savings.

Christian Terwiesch (with Kevin Volpp again) writes about the Penn medicine innovation tournament, a brilliant effort to engage the thousands of employees who work in the Penn healthcare system to submit ideas to improve their delivery system.  They received over 1,700 ideas.  Beyond the great ideas, the biggest benefit of the tournament might have been its effects on the culture at Penn, where the tournament made clear to employees that “their ideas and participation are valued.”

Andrew Ryan and Cheryl Damberg, who have previously written extensively about pay-for-performance (P4P), have an important summary piece about what we know about P4P and what it can tell us about future federal policy efforts in this area.  Last, but not least, is an excellent interview with Mark McClellan, another former administrator of CMS (and so much more).  Among other things, McClellan discusses the promise of ACOs and why he thinks they might be an important source of innovation in healthcare delivery.

So there you go – an amazing issue.  Navathe and Jain deserve credit for getting the journal launched, but extra credit goes to Rachel Werner and Melinda Buntin, who co-edited the issue and put together an amazing line up of articles. The gains in healthcare quality and efficiency that could come simply from the insights in the inaugural issue are substantial.   They have set the bar very high for the next issues that follow.  Stay tuned.

Racial disparities in health and healthcare are a persistent and troubling problem for the U.S.  Despite substantial policy efforts to the contrary, racial and ethnic minorities, especially African-Americans, often receive a lower quality of care and have worse outcomes.  The key questions, of course, are why do these disparities exist, and what might we do about them?

Over the past decade, two primary theories have emerged to explain disparities and propose solutions to address them.  The first focuses on issues around cultural competence, and suggests that many of the gaps in care are due to poor communication between providers and patients.  Given the long history of discrimination against black Americans, the cultural competency theory argues that low trust on the part of patients, combined with the ineffective communication and lack of cultural sensitivity, leads to black patients receiving worse care with resultant poor outcomes.  Ultimately, the cultural competency theory begs an approach to health disparities that requires more effective training of providers that care for minority patients.

The second theory of racial disparities in care suggests that the site of care really matters, that disparities are driven by the fact that black patients are more likely to receive care at poor quality hospitals.  There is ample evidence for this theory as well — our prior work showed that care for black patients is highly concentrated among a small number of hospitals and these places generally provide a lower quality of care for all their patients.  This theory calls for a somewhat different set of solutions:  focusing on helping the subset of “minority-serving” providers to improve.

The Dimick Study

Of course, there need not be any contradiction between these two theories and one may suspect that both are likely at play.  It is in this context that we have a terrific new study by Justin Dimick and colleagues from the University of Michigan, in the newly released June issue of Health Affairs, that helps us better understand why black patients generally have higher mortality after major surgeries than their white counterparts, and how we might try to reduce this gap.

Dimick and coauthors began with the observation that we’ve known for some time: that black patients more often receive surgical care at lower-quality institutions (that is, hospitals that have high mortality for both their white and black patients).  What we haven’t known is why black patients end up at lower-quality hospitals.  The conventional wisdom has been that black patients live in neighborhoods with poor quality institutions, and they, like everyone else, usually use the nearest hospitals.  So, Dimick and colleagues sought to test this hypothesis.

Their results?  In fact, they found the opposite:  when it comes to surgical care, black patients are more likely to live near a high-quality hospital with lower mortality rates for all patients.  Yet, surprisingly, they are likely to bypass these institutions to receive care at lower-quality hospitals.  How could this be?  And, what might we do about it?

One might question whether a large part of why black patients receive care at lower-quality hospitals is historical.  Until 1964, hospitals were legally segregated institutions, with most hospitals only caring for white patients and a smaller number caring only for black patients.  Even with the advent of Title VI of the Civil Rights Act, which ended formal segregation in U.S. hospitals, long-standing patterns have proven hard to change.

Doctors who work and serve in predominantly black communities may continue to make referrals to traditional “minority-serving” hospitals.  Patients may choose to go to these institutions because they are familiar with them and may feel more comfortable receiving care there.  Indeed, in my own clinical experience, I have known several black patients to be more likely to seek care at what they perceive to be traditionally ‘black-serving hospitals,’ in spite of the proximity and availability of other, sometimes higher-quality, hospitals. Their rationale had more to do with their comfort and historical precedent than actual hospital quality.

Finally, there is the issue that many of these traditional minority-serving hospitals care for large proportions of patients on Medicaid or with no insurance at all, creating substantial financial stress on their capability to provide high-quality care.

The Path Forward

So given the entrenched patterns of care, the complex issues around doctor referral, patient choice, and hospital financial capabilities to deliver high-quality care, what might we do?  I think the solutions, while appearing quite straightforward, have been hard to implement. Dimick identifies a few, and it’s worth going into greater detail with the hope that they may become a reality sooner rather than later.

First, we can work on improving referral patterns.  It’s possible that doctors who refer black patients to low-quality hospitals are unaware of the consequences of their referrals on their patients’ outcomes.  The Centers for Medicare and Medicaid Services (CMS) could easily send each physician an annual report card about the outcomes of care at the institutions where they commonly refer their patients.  A report card to a cardiologist showing that 80 percent of their patients received surgery at a high-mortality hospital when other, low-mortality hospitals were available nearby may offer an important incentive to change.

Improving referrals is unlikely to be enough and we have to acknowledge that many patients will continue to get treated at low-quality hospitals.  Therefore, we need to simultaneously work to ensure that these hospitals improve.  For things that are largely within the hospital’s control, such as surgical mortality, we should have a national standard and hold every hospital accountable for meeting it.  And this needs to be given teeth, by putting substantial payments at risk for poor patient outcomes.

But large penalties for poor performance are not enough and may worsen disparities if hospitals don’t know how to respond effectively.   CMS needs to help these hospitals get better.  CMS can use its convening power to bring minority-serving institutions together to learn from each other.  With large financial penalties at stake for those who fail to improve, hospitals will be motivated to collaborate.  Asking these institutions to learn from each other is far more likely to generate effective solutions than asking one of these institutions to learn from a wealthy neighbor across town that cares for a very different patient population.

The factors underlying healthcare disparities are many, complex, and shaped by the long history of race relations in the U.S. Luckily, there are concrete actions policymakers can take to make things better. We have broad consensus that the color of your skin should not determine the quality of care that you receive.  Yes, there have been efforts to reduce racial disparities, but they have clearly not been enough.  The time to redouble these efforts is now.

Published on the Health Affairs Blog, June 4, 2013 Copyright ©2013 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.