Delivery System Reforms: Delivering Value?

Restructuring health care delivery to reduce costs and improve quality is a fundamental part of the Affordable Care Act (ACA) and a response to the long history of high domestic healthcare spending with suboptimal outcomes. In fact, the ACA mandated programs such as and before there was clear evidence demonstrating their effectiveness.

In this study, authors performed a systematic review of studies of system-level interventions to impact health care value, defined as a balance between quality and cost. They searched PubMed for analysis of PCMH (n=12), P4P (n=10), and mixed interventions (n=6), identifying 30 reports of 28 suitable interventions and reviewed quality, cost, and utilization. In assessing value, they delineated positive as 1) increased quality with no change or reduction in cost/utilization or 2) no change in quality with a decrease in cost/utilization and negative as 1) reduced quality with no change in or increase in cost/utilization or 2) no change in quality with an increase in cost/utilization.

Twenty-three reports showed improved value, 1 decreased value, and 6 unchanged, unclear, or mixed results. Commonly reported outcomes included rates of HbA1C testing in diabetics (n=14), lipid testing (n=14), cancer screening (n=11), readmission (n=7), composite quality measures (n=5), patient satisfaction (n=5), and diabetes control (n=5). Two studies measured overuse of diagnostic studies. Of note, the majority of interventions occurred at primary care practices, with few hospital and specialty care sites included. There was large variability of sample sizes and follow up times. There was no information on patient or practice demographics.

The authors certainly undertook a noble effort to identify outcomes for in a time when policy is put into law without hard evidence. The general conclusion of this study indicates that the majority of such efforts result in value positive outcomes; however, it is difficult to extrapolate these results to any larger purpose due to small number of studies, high variability of study methods, and absent demographic information. Furthermore, the quality outcomes (screening rates, readmission, etc.) have yet to prove long term significant improvements in health or healthcare spending.

As the ACA continues to have large scale impacts on healthcare delivery, it is imperative to continue evaluation of its programs for effectiveness, feasibility, and patient and provider satisfaction. As policymakers move forward with new and changed policies, it is crucial that they as opposed to surmising that something is good just because it sounds like a good idea.

Abstract

Widespread restructuring of health delivery systems is underway in the United States to reduce costs and improve the quality of care. The authors evaluated published articles that reported value outcomes of new programs such as Patient-Centered Medical Homes and Pay-for-Performance. Improved value was reported in 23 of 30 reports as improved quality, cost, or utilization. Study limitations included variability among specific endpoints reported, inconsistent methodologies, and lack of full adjustment in some observational trials. Overall, the literature suggests that health system reforms can improve value, but extrapolation of these results to greater outcomes remains very limited. PMID: 26492216

Korenstein, D, et al. Med Care. 2015 Oct 21; epub.