Tuesday, September 16, 2008

Dr. Berwick's vision

The closing keynote address at the conference was given by Don Berwick, President and CEO of the Institute for Healthcare Improvement. It was entitled Health Care Leaders and the “Triple Aim”. It’s risky to summarize a Berwick talk because it is always well constructed and elegant. I’ll take a chance with a few highlights.

His focus was on what’s left to do, rather than what’s already been done. There’s a lot to be done. There is a big gap between what we have and what we could have. Looking at what is spent in the US on health care, we see that we spend a lot, and we do not get our money’s worth -- either in terms of access or results. We need to grapple with the fact that we have a low value system.

It is also a system characterized by extreme variation in spending, over $3000 per capita in Medicare spending between the lowest quintile and highest quintile parts of the country. There is no positive correlation between spending and results. In fact, it is a negative correlation. In other words, this is $3000 of negative return.

We don’t have one big problem here. We have two, and this requires a sophisticated and parsed solution with two separate paths.

One path is about getting better care when you are sick. This is based on achieving the following dimensions of excellence when you are sick and need care: Safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. This is done by designing better processes and deploying them.

The second problem has to do with the drivers of the low value system. On the high cost side, this derives from the constant entry of new technology, drugs, and the like without documented relationships to outcomes; no mechanism to control costs; and supply-driven demand. On the low-quality side, it comes from over-reliance on doctors for things that non-doctors can do; no foreign competition; and undervaluing system knowledge.

Berwick’s approach to this is defined as the “Triple Aim”: Improve the experience of care + raise the level of the health status of the population + control the per capita cost. He states that the root of the problem is that the business models of almost all health care organizations depend on keeping these aims separate. Berwick proposes a system that will focus on individuals and families; offers strong primary care services; provides population health management; imposes a cost control platform (i.e., a strict population budget); and enforces system integration to make this all happen.

8 comments:

Anonymous said...

"There is no positive correlation between spending and results."

Just like your salary.

nasov said...

An uncivil remark and for that reason I am disappointed that Mr. Levy posted it for you. I know he believes in this kind of openness. But really, f you have a problem with Levy's leadership, post it and be specific. I'm pretty sure he can take it. He might even agree with you!

Tom Emswiler said...

Shameless plug: I published a four-part "blog mini-series" on the IHI Triple Aim seminar this past July. Just in case it's of interest...

http://www.newamerica.net/blog/new-health-dialogue/2008/reform-ihi-s-triple-aim-rolls-dc-part-i-introduction-4898

http://www.newamerica.net/blog/new-health-dialogue/2008/reform-ihis-triple-aim-rolls-dc-part-ii-population-health-5004

http://www.newamerica.net/blog/new-health-dialogue/2008/reform-ihis-triple-aim-rolls-dc-part-iii-patient-experience-5032

http://www.newamerica.net/blog/new-health-dialogue/2008/reform-ihis-triple-aim-rolls-dc-part-iv-cost-containment-5079

jessica lipnack said...

Congrats, Paul, on your first efforts at live blogging. It's wholly possible that you are the first CEO to have ever tried this, or at least the first hospital CEO. Takes humility and a helluva lot of energy to keep up, type, post, and be present. Now you know what stenographers feel like - only they have machines made for it.

Don Berwick said...

I appreciate Paul's accurate and efficient summary of my remarks. The "Triple Aim" framing, which was initially published in Health affairs (Berwick DM, Nolan TW, Whittington JW. The triple aim: care, health, and cost. Health Affairs 2008; 27: 759-769), is challenging, esepcially to hospitals, and especially in the status quo payment system. We'll need all our wits and creativity, all together, to move in that direction. I'd welcome further comments -- on Paul's blog if you wish -- to help us make progress and learn. Thanks.

Anonymous said...

Dr. Berwick should offer his insight as to how doctors and hospitals should be paid in order to facilitate achieving the triple aim. Dr. Levy, your thoughts would be welcomed as well. NZ

Paul Levy said...

Since I am not a doctor, I'll defer to him! (But see my first post about this conference, below.)

Göran said...

JF Kennedy Library was a perfect place to hold a conference about Charles K;s book. The whole house is about courage, faith, and the importance of positive visualization. For me Don B and Paul L and Charles K symbolize this so well. Go outside your frame and make your doing to a positive provocation based ´n solid values and a strong vision.