Policy Roundtable Abstracts - AcademyHealth

COST: Panelist Michael Chernew, PhD, from
the Harvard Medical School will summarize his research
on differing mechanisms to control healthcare spending
growth while maintaining quality of care. Specifically, Dr.
Chernew will highlight the challenges in collecting and
standardizing cost data, discuss consumer incentives
and value-based insurance design, and discuss how
alternative payment models may align with the goals of
IHI’s Triple Aim initiative.
PATIENT EXPERIENCE: Panelist Elliott Fisher,
MD from The Dartmouth Institute for Health Policy and
Clinical Practice will briefly summarize the many lessons
learned from three decades of variation research on
patient outcomes and the patient experience. Dr. Fisher
will give special attention to his landmark findings
illustrating the disconnect between utilization volume and
patient outcomes and the implications of unwarranted
variations for patient safety and quality of care. He will
conclude by discussing the potential of newly proposed
initiatives to stimulate and support accountable delivery
systems.
POPULATION HEALTH: Panelist David Kindig,
MD, PhD from the University of Wisconsin School of
Medicine and Public Health will draw on his experience
as co-director of CountyHealthRankings.ORG and the
Mobilizing Action Toward Community Health (MATCH)
project to discuss measurement of the social and
environmental determents of health and their interaction
with the healthcare system when quantifying the health
of a population. He will also discuss the synergies and
conflicts between conceptualizations of population health
in the Triple Aim and MATCH models.
PERFORMANCE MEASUREMENT: Panelist
David Radley, PhD, is a measurement expert at the
Institute for Healthcare Improvement and The
Commonwealth Fund. Dr. Radley will draw on real-world
examples (based on IHI collaborations with
organizations currently pursuing improvement activities
around the Triple Aim concepts) to discuss the unique
challenges of simultaneously measuring performance
across the three dimensions of the Triple Aim. He will
describe his experience creating locally representative
health system performance scorecards and will discuss
the collection and use of systematically defined ‘local’
data to measure health system performance and
motivate improvement.
Healthcare system design and re-design should
simultaneously aim to improve population health,
enhance the patient experience, and reduce per capita
healthcare spending. Proposed and legislated
healthcare reforms can go a long way to achieving better
performance on each of these dimensions. However,
success also requires the development of data systems
and carefully defined metrics that are accessible to
evaluators, a recognition of and commitment to
addressing the community-based determinants of
population health, a common purpose and the adoption
of mechanisms to control per capita cost, and most
importantly, engagement from motivated local entities
that are willing and able to support a defined population
and ensure the existence of systems that align
healthcare services with individual’s needs.
Reducing Readmissions: Practice, Payment, or Pot
of Coffee
Organizer/Moderator: Amy Boutwell
Monday, June 13 * 4:45 p.m.–6:15 p.m.
Panelists: Arnold Epstein, M.D., M.A., Harvard
University; Jane Brock, M.D., M.P.H., Colorado
Foundation for Medical Care; John Young, Centers for
Medicaid and Medicare Services
Roundtable Summary: Hospital readmissions are of
major policy interest because they occur frequently, vary
across settings, and offer the potential to simultaneously
reduce spending and improve patient outcomes. In
recent years clinical leaders and policy makers have
tried many approaches to reducing readmissions. Some
of these efforts are directed at quality of care during and
after discharge and focus on improving discharge
planning, assuring timely follow up and providing better
transitional care. Other efforts focus more generally on
ambulatory care and seek to provide better disease
management and improved coordination of care. More
recently there has been interest in changing the
underlying incentives for using hospital services. The
Center for Medicare and Medicaid Services is planning
to initiate programs to "bundle" payment for all the
services around a hospitalization, and to provide shared
savings for accountable care organizations. This Policy
Roundtable will bring together policy makers, clinical
leaders and researchers to describe and discuss
ongoing and future efforts to reduce unnecessary
readmissions. The four speakers and the topics that they
will cover are described below.
Arnold M. Epstein, Chair, Department of Health
Policy and Management, Harvard School of Public
Health. Dr Epstein will describe recent research
examining the variation in rates of readmission across
different Hospital Referral Regions (HRRs) as identified
in the Dartmouth Atlas and the factors that explain this
variation. Dr. Epstein and his collaborators found that
rates of readmission within 30 days after index
hospitalization for congestive heart failure or pneumonia
vary more than three fold from 11% to 35%. The most
important factor explaining readmissions is the
propensity to hospitalize as measured by the population
based all-cause admission rate in the HRR which
explained roughly 35% of the variance in 30, 60 and 90
day readmissions. Bed supply was also important.
Comorbidity (the 29 co-morbidities in the Elixhauser
schema), measures of discharge planning (as
ascertained by the hospital version of the Consumer
Assessment of Health Plans Survey (H-CAHPS) data)
and other supply side factors (number of primary care
physicians, and number of specialists in cardiovascular
or pulmonary medicine per 100,000 persons in each
HRR) explain little of the regional variation.
These findings underscore the importance of
general propensity to hospitalize patients and the
number of beds available. Policy initiatives designed to
lower the propensity to use hospital services may be