We’ve heard it before…healthcare costs are rising faster than quality is improving. Significant waste in healthcare delivery persists, harming patients, providers, payers, and purchasers. Providers who do the right thing—improve quality, reduce waste—are penalized financially in a fee-for-service reimbursement environment. Healthcare cost and quality data are largely unavailable to purchasers and consumers, so the market can’t reward the “good guys.” And patients’ health conditions must be addressed not just inside a clinic or hospital, but also where the root causes of our most common and costly health conditions are found: where people live, learn, work and play.
Improving value in healthcare—better care at lower cost—requires that we solve what social scientists call a "wicked problem." Wicked problems share the following characteristics:
- The problem affects many different sectors of society, and the problem is defined differently by those sectors.
- There are no clear solutions to the problem, and there certainly is no single solution.
- There is a long history of failed attempts to solve the problem.
- Some of those past attempts have led to unintended consequences that are now new problems.
- Solutions require major change in policy, and organizational and individual behavior.
- No one organization, or sector, can solve the problem on its own.
John Kania and Mark Kramer with the non-profit consulting firm FSG have articulated a framework for finding a way out of wicked problems like creating greater value in healthcare. It’s called "collective impact," and it has five core elements:
1. A common agenda –participants from diverse organizations and sectors have a shared vision of the work they will do together, including a common understanding of the problem and an agreement to work on solving it together
2. Shared measurement– participants agree to collect data and be accountable to agreed-upon measures of success
3. Mutually reinforcing activities – participants do what they can to move the needle on the common agenda – participants may do different things, but their activities are coordinated
4. Continuous communication – participants keep in touch with each other to build trust and facilitate alignment of effort
5. Backbone support – an organization, or several organizations, serve as convener and facilitator, without advancing a preconceived idea of what the “right answers” are, but rather creating the space for the group to arrive at those solutions together.
Here in Wisconsin, with important leadership from John Toussaint, MD, and the ThedaCare Center for Healthcare Value, we are endeavoring to realize greater value in healthcare, faster, by bringing leaders of our statewide organizations and efforts in quality reporting, all-payer claims data analysis, and payment reform together with leaders in the provider, payer, purchaser, and state government communities. This group has established its common agenda: realize greater value in healthcare faster. We’ve created a Statewide Value Committee that has endorsed an initial set of 17 measures of value. We’re moving on now to identify those activities in which participating organizations already are engaged, and perhaps some new things, that can be better aligned to move the needle faster in these areas of care:
|Cancer Screening||Early elective delivery|
|Patient satisfaction – ambulatory and inpatient||Catheter associated UTI|
|Childhood immunization||Central line infection|
|Diabetes outcomes||Unplanned all-cause readmission|
|Hypertension control||Total resource use|
|Ischemic vascular disease outcomes||Total cost of care|
Improving Wisconsin’s performance in these areas will require us to better align our currently siloed initiatives in care delivery redesign, transparency of cost and quality metrics, and payment reform. Working together, across organizations and stakeholders, we’re going to attempt to drive real alignment and focus of measurement and related activities, to cut through the “measure confusion” that consumes limited resources without returning real value to anyone. Only by better integrating care redesign, transparency, and payment reform at the start, not as an afterthought, can we realize the results and industry transformation we all are after.
Collaboration is hard work. It can be slow. No one gets 100 percent of what they want. But it’s also the only way to go when working on a wicked problem like value in healthcare.
Director of the Partnership for Healthcare Payment Reform (PHPR)