By Jonathan B. Perlin, MD
In health policy, we aspire toward the “triple aim” of better health, better care and better cost for our country. Indeed, the cost-growth of health care has slowed profoundly over the past half decade. Studies show this is in part due to the economic downturn, but more substantially reflects structural changes that are checking increased resource use. What may be less obvious is that the care itself is better, and that better care is almost always less expensive.
Performance measures providing transparency and accountability foster evidence-based practice, leading to more efficient care delivery. Avoiding complications not only prevents harm, but also prevents unnecessary expenditures. What may be less obvious is that discontinuities in insurance coverage that lead to discontinuities in care are also inefficient. In short, it is easier, less expensive and certainly more compassionate to address health risks and treat disease early than to wait for catastrophe. Thus, our march toward the triple aim demands a true system of care that aspires to promote health, prevent disease and manage chronic illness.
Long before the passage of the Affordable Care Act, hospitals across the country were working to improve fragmented care delivery. As we realized our focus has been more on “sick care” than “health care,” we realized our need to revise our compact with patients. The familiar sign depicting a white “H” on a blue field has always symbolized hospitals’ commitment to be there for illness. Reinventing the “H” and delivering on the promise of the triple aim requires that we be there in both sickness and in health. This vow requires the continuing support of our legislators and policymakers.
At the onset of the economic downturn, nearly 50 million Americans had no health insurance and hospitals were admitting sicker patients. At the same time, this meant providing more charity care, which in turn increased the level of uncollectible debts. Insurance premiums and out-of-pocket costs were increasing, while an aging population, changing communities and disparities in care posed additional challenges.
But with these challenges came new opportunities. Better information technology created the means for hospitals to analyze patient data and tap into our collective knowledge to define best practices. Hospitals also began to more accurately measure performance and work tirelessly to develop and share ways to improve quality, such as through protocols that minimize infections that are now understood to be preventable.
The American Hospital Association has played a leadership role in this process by providing a hub for exploration and information sharing, and for leading quality improvement efforts. Through “Hospitals in Pursuit of Excellence,” its strategic platform to accelerate performance improvement, the AHA provides field-tested practices, tools, education and other resources that support hospital efforts to meet the Institute of Medicine’s Six Quality Aims—care that is safe, timely, effective, efficient, equitable and patient-centered.
The new requirements for demonstrating value are bringing profound cultural change to health care and hospitals. Boundaries that once separated clinicians from administrators, hospitals from medical offices and medical offices from patient homes are increasingly dissolving. Still, the business case for a full system of health care is incomplete and it cannot be built successfully as a derivative of sick care. Achieving the triple aim requires an evolution of care model—and the business model—from episodic to continuous.
A Shared Vision
The AHA consulted with hospitals, patients, physicians and other stakeholders across the country to create a framework to transform America’s health care. Called “Health for Life,” its five essential elements have guided the AHA’s policy development regarding health care reform. They are:
Focus on wellness. Good health—physical, mental and oral—is essential for a productive and vibrant America. A focus on wellness must be integrated into our lives, from birth to death, and be encouraged in our homes, schools, workplaces and communities.
The highest quality care. Doctors, nurses, hospitals, nursing homes and others must work together with patients and families toward zero avoidable harm and use of the best science to achieve optimal outcomes.
The best information. Informing the decisions of patients and caregivers across settings and over time coordinates the team. It also creates a platform for measuring and assuring performance and for a learning health system that advances the science of health care.
The most efficient, affordable care. We cannot be satisfied until the cost of health insurance and health care are affordable. Reliable, science-based, patient-centered and continuous care is most efficient.
Health coverage for all, paid for by all. Health coverage for all is everyone’s shared responsibility, and individuals, businesses, insurers and governments must play a role in expanding and paying for it. Not having insurance or being functionally underinsured is not a low cost model; it is a “sick care” model, and cost-shifting to those with coverage fails to solve the inherent inequity and inefficiency.
Additional information on the five essential elements of “Health for Life” and details for implementing them may be found at the AHA website, www.aha.org/advocacy-issues/healthforlife/index.shtml.
Hospitals began implementing new regulations and preparing for increased coverage almost as soon as Congress passed the Affordable Care Act. Hospitals already are becoming more integrated as systems. Yet at the same time, funding for hospital services has been cut by more than $100 billion since 2010, putting a significant financial burden on the hospital industry.
Last year was a demanding one for hospitals, and 2014 continues to bring even more profound change—but we are pleased to be changing. We are implementing electronic health records while simultaneously navigating new penalty programs and payment models and a host of other new regulations, most with very ambitious timelines. Many hospitals have been helping their communities enroll in the new health insurance marketplaces and are treating newly covered patients. We continue to focus on quality and patient safety, implementing more evidence-based improvement efforts. These are costly changes that must be made by all hospitals, whether or not we see coverage gains.
As we move toward a more coordinated system of care, we are committed to working harder to keep people healthier and find ways to change in order to better meet the needs of our communities. We will work to identify and eliminate costly treatments that don’t improve patient outcomes and move care into our communities in nontraditional ways. Some hospitals will merge with others to benefit from economies of scale that can help provide the latest treatments, access to new technologies and preserve the presence of caregivers at the bedside in America’s communities.
As American hospitals navigate toward a new future, expect us to step up our outreach efforts to individuals, families and entire communities—and to our elected representatives. Outreach at the community level will encourage people to get the preventive care they need. We will partner with organizations that help patients stay healthy after discharge from our facilities. And, we will turn to our legislators to work with us to support our efforts to keep health and health care where they belong—in our communities.
We will work together to redefine the “H” seen in that familiar, blue, hospital sign. That “H” has always been America’s national symbol for “hospital” to let everyone know that if they were sick, hospitals are there to care for them. We are striving to redefine that “H” for the future, for it to become a symbol, not only of American hospitals’ commitment to the triple aim, but of America’s commitment to the complete health of its citizens. We must do this not just because we are a compassionate country; we must do this because it is most efficient.
Jonathan B. Perlin, MD, PhD, MSHA, FACP, FACMI, is chair-elect of the American Hospital Association. He is president for clinical services and chief medical officer for Hospital Corporation of America.