Innovative approaches help improve the managed care trifecta

June 1, 2005

It is no surprise that many healthcare organizations are content with the status quo. But is the status quo good enough? According a World Health Organization report from 2000, the United Status spends more on healthcare than any other country in the world, but only ranks 37th in health system performance.

The healthcare industry is a field that rewards routine. As patients, we want our doctors to be rigorously trained and treat many other individuals with our same health condition. We don't want doctors to experiment and think "out-side-the-box" when they are treating us. So it is no surprise that many healthcare organizations are content with the status quo. But is the status quo good enough? According a World Health Organization report from 2000, the United Status spends more on healthcare than any other country in the world, but only ranks 37th in health system performance.

It is time to encourage change and innovation in order to begin the uphill journey toward improving the quality of patient care. The good news is that there are cost-effective methods to go about doing so.

Participate in Pay-for-Performance Systems. Pay-for-Performance (P4P) encourages medical groups and hospitals to provide good quality care by financially rewarding high scorers in categories that have been proved through evidence-based medicine to represent best-practice medical care.

Once scores have been reviewed, actively set up processes to improve them. Payments may be made to organizations who score statistically higher than the mean score or who score within the upper quartile of all participating organizations. In order to increase the likelihood of receiving payments each year, the organization must constantly improve, regardless of whether it scored well in the past year.

Establish Evidence-Based Clinical Guidelines/Protocols. For certain conditions and certain types of patients, there is a consensus on which treatment constitutes good quality care (e.g., annual sensory foot exams for diabetes patients). Developing protocols and clinical guidelines to encourage administration of appropriate care (as identified through evidence-based medicine), increases the quality of patient care and increases process standardization. By increasing the standardization of care, nurse and physician time spent stabilizing/treating patients decreases, which increases the ability to see more patients in a given day and therefore increases daily reimbursement.

Use Disease Management Programs as a Method to Manage Patient Care. Disease management programs increase the proactive management of patients with chronic conditions, who tend to be high users of healthcare. By identifying the origin of diseases, the root of the resulting health problem can be targeted.

Identify Conditions that You Excel in Treating and Promote Them to the Community. Use performance metrics, such as HEDIS or JCAHO Core Measure scores, to identify health conditions on which the organization scores highly. If there is room for improvement in these scores, develop processes to make improvements. Once the organization scores above the targeted performance level or above other organizations in the community, advertise the fact that the organization is a leader in the treatment for that condition. Furthermore, if this health condition is also reimbursed well, profits will increase at the same time.

Hire Individuals Who Make You Uncomfortable. Take a moment to consider the theory of Robert Sutton, a professor at the Stanford Business School, who wrote "Weird Ideas that Work." Sutton's justification of this strategy is that people tend to be attracted to others that are similar to them. In order to get a better cross-section of ideas in an organization, it is important to hire individuals who think differently than the norm. This strategy should not be employed for hiring healthcare providers, but for healthcare organization management, it is important to be surrounded by both doers and thinkers. Many people who work in healthcare organizations are doers. In order to embrace the change process needed to increase quality of care and operations and to think about strategic visions for these organizations, more thinkers are needed in the industry.