Feature / Quality response

The traditional approach to cost pressure is to cut services to save money. But Don Berwick, the leading US advocate for high-quality healthcare, has for a long time called for a different response. His theory, developed and refined at the Institute for Healthcare Improvement (IHI), where he was the founding chief executive officer, is that when you make care better, costs go down. His mantra hasn’t changed, but what is different is that the theory is becoming a practical reality. ‘This is not wishful thinking,’ he told the HFMA annual conference in December. ‘We can now visit places where this is actually happening.’

All health systems face similar challenges, with demographic changes leading to an increase in demand, a rising incidence of chronic disease and the need to meet the costs of new technology and drugs. And this needs to be done in a very harsh financial environment.

However, Dr Berwick – a paediatrician by background and a former head of the US Centers for Medicare and Medicaid Services (CMS) – insists the scarcity of additional finance should not itself present any difficulties. He points to studies that estimate 21% to 47% of health spending in the US is wasted – adding no value to patients. A midpoint estimate of 34% includes waste across six areas:

• Failures of care delivery
• Failures of care co-ordination
• Overtreatment
• Administrative complexity
• Pricing failures
• Fraud.

‘There’s the money,’ said Dr Berwick. ‘That’s one in three dollars – so this is an internal recovery job.’ This waste, he suggests, is likely to be present in all health systems to different degrees. But the key to financial improvement is better quality care, Dr Berwick said, and evidence is growing to back this statement.

He highlighted the IHI’s central line bundle initiative, which has contributed to a more than 50% reduction in central line-associated bloodstream infection in intensive care patients. (A central line is where a catheter or intravenous tube is introduced into a large vein to administer fluids or medicines.)

The bundle effectively pulls together basic steps such as hand hygiene, the use of chlorhexidine skin antisepsis kits and the daily review of line necessity. As well as saving lives, the reduction in infections has avoided unnecessary treatment costs – costs that were previously taken for granted. Dr Berwick said some hospitals had shown it was possible to get to a zero infection rate.

Dr Berwick is on the record as praising elements of the NHS – which caused him difficulties while at CMS (see box) – but he told the HFMA conference his eye was currently being drawn to Scotland. ‘Scotland is now headed to be the safest healthcare system on the planet,’ he told the conference – a clear reference to the Scottish Patient Safety Programme, which should pay off in financial as well as patient improvement terms if Dr Berwick’s claims are correct.

He offered other examples of higher quality leading to lower costs. The Nuka healthcare system delivered by non-profit organisation South Central Foundation in Anchorage Alaska, for example, has had spectacular results. A multidisciplinary team-based approach to delivering primary outpatient care to groups of patients (about 1,400 per group) is underpinned by detailed data on clinical and financial performance. Dr Berwick listed the high-level outcomes:

• Urgent care and emergency room use down by 50%
• Hospital admissions down by 53%
• Specialist use down by 65%
• Primary care use down by 20%.

Add to this customer and staff satisfaction above 90% and it is understandable that other US healthcare systems are taking an interest.

Telemedicine solution

Elsewhere in Alaska, Dr Berwick singled out the use of an Afhcan cart as part of a telemedicine solution to the problem of delivering care to remote populations. The cart is effectively a mobile health workstation combining numerous clinical instruments with videoconferencing technology, allowing data to be captured locally and analysed by specialists remotely, cutting out unnecessary travel for patients.

Dr Berwick also highlighted work in Denver Health, a safety net group of hospitals in Colorado. The system has significant challenges – more than 40% of its patients do not have insurance. Yet it has become a leading light in healthcare delivery in the US. Early adoption of Lean management principles has helped it improve quality (regularly topping league tables with the lowest mortality rate among academic health centres) and has lowered costs (claiming $143m of Lean benefits since 2006).  

As a final example, Dr Berwick highlighted the development of self-care for patients needing haemodialysis in Sweden. The programme started at Ryhov hospital in 2005 and now 60% of dialysis patients are on self-dialysis. Costs have been halved and complications reduced, with success measured in terms of the numbers of patients working.

Sweden is not the only country pursuing this approach – the UK is increasingly offering self-care – but Dr Berwick said health systems in general had not fully grasped how much patients could do for themselves.

In the US, Dr Berwick said it was easy to imagine a better system, particularly with the growing examples of higher quality, lower cost services, but the problem was in the transition. ‘There is opposition,’ he said. ‘The hospitals don’t always like it. They are used to activity and using their power to exercise pricing controls, but they are not all willingly moving into more integrated care. The best hospital in future may be a smaller hospital.’

He said many insurance companies were ‘rallying around the status quo’. And while much of the public ‘isn’t with us yet’ – clinging to the belief that more care is better care – ‘the reality is that integrated care is better care, not necessarily the next test or the next drug’.

Dr Berwick said payment systems in the US were starting to move towards volume-based systems rather than fee-for-service. Asked whether the market could deliver the required change, Dr Berwick urged caution.

‘The role of competition among providers is at least double edged and probably weak in healthcare,’ he warned. Instead, he added, ‘transparency offered a good form of competition’ – with clarity around cost, variability and outcomes helping to drive improvement. However, he said investing in the capacity of primary care as the agents for local populations made a lot of sense.

Dr Berwick concluded with an acknowledgement of the difficult financial context facing both the US and other international health systems. But he suggested that the current climate also presented an opportunity for healthcare professionals to lead the reform programme. All health systems should be able to sign up to the triple aims of ‘better health, better care and lower cost’.