Over the past decade, we have been immersed in quality improvement. Pressed by our regulators, our payers, our patients, our communities, and our professional selves, we have brought singular focus to improving the quality of the care we deliver and the safety of patients in our care. We have seen measurable results. Many hospitals report reduced infection rates, fewer medication errors, and increased adoption of, and compliance with, evidence-based protocols. More patients are surviving their hospital stays; fewer are subject to adverse events.
Yet, these initiatives and our progress bring complex new challenges. As we seek to improve quality, we also seek to be more efficient - to provide greater value at less cost. Parallel to the demand for quality improvement, new reimbursement structures continue to evolve, offering significant incentive to thrust us toward further change. In her commentary, Catherine Jacobson captures this point: "Nothing changes behavior in healthcare faster than a change in reimbursement."
Reductions in reimbursement have resulted from initiatives such as readmission policies and bundled payment. In the face of that tightening reimbursement, we can't fault policies that stop payment for the cost of fixing the adverse outcomes of never events. After all, why should taxpayers, employers, or patients have to pay for the results of clinical errors that should never have happened? The wrong-site surgery that was wholly preventable, the line infection that would not have happened had we followed infection-control protocol, and similar mistakes have caught the attention of policymakers and payers and have garnered a predictable response: the cost of the fix belongs to the provider, not the payer. No longer are those costs reimbursed. Zucker points this out succinctly in his comment that "health policy, and in particular reimbursement policy, has made a decided shift toward pay-for-performance, value-based purchasing, bundled pricing, and other forms of reimbursement that shift the burden of risk back to the providers and reward them for producing value."
As reimbursements dwindle, hospitals and health systems have had to be creative and strategic to maintain a viable revenue stream. Efforts to deliver increased value and improved quality have had to be built on a base of solid, positive financial performance. Rutledge, Huber, and Mathews advise that "quality without financial performance is not sustainable in the long-term." Their feature article explains in depth that "while it is not always possible to attribute the impact from individual initiatives, the impact of concomitantly improving quality outcomes, reducing costs, and efficient operations is synergistic and interdependent." Ultimately, they report that their health system, CaroMont, found that "quality and efficiency are interlinked."
Byrnes and Fifer build on this theme in a discussion of the importance of integrated systems that are not just an "assemblage of the required components" but are organized in a "true functional integration where patients experience a seamless continuum of care that is highly coordinated, efficient, effective, and accessible." Both feature articles note the importance of two key elements: (1) accountable and effective medical leadership and (2) a reporting system that matches clinical and financial data.
The change that healthcare providers are making today is, at its core, a revolution in healthcare delivery. As fee-for-service is replaced by new models of reimbursement, provders will be drawn closer together in teams, patients will move to the front and center of our focus, and our organizational and payment structures will bring physicians and hospitals into deeper alignment, as Kuhn suggests in his commentary, "Forcing providers to integrate information and care delivery in new ways."