Monday, June 1, 2009

Measuring Health Value - Shifting the Paradigm

The Healthcare X PRIZE will be introducing an new health value measurement framework that will help focus on health care outcomes at a community level.

The Healthcare X PRIZE (HXP) is being designed to create a next generation health system that increases efficiency, reduces costs, and improves health value. In order to drive this transformation, there needs to be a new way to measure, monitor, and improve the health care outcomes across the different interventions in local health delivery systems. There are currently a wide variety of measures and metrics used to evaluate health care, but these measures have not been utilized in a way that drives the delivery system to optimize for health care value at a both population and individual levels.

As part of the breakthrough aspirations of the HXP, we intend to create new measures and metrics that focus on comparing different systems of health care delivery and financing and how they impact Health Care Value (HCV). Measuring the value produced by a health care system remains a difficult challenge which to date has prevented the meaningful comparison between different systems of care. We believe emphasizing health care value is the appropriate point of focus to leverage market competition in allocating resources efficiently and effectively.
Furthermore, focusing on HCV [outcomes /cost] provides a useful framework to direct attention to removing disparities by maximizing improvements at a population health level.

We believe the creation of a Community Health Index (CHI), which would combine broadly accepted and actionable population health measures (each with varying weights based on relative impact) would achieve this objective. It is currently unclear how many measures are required to give us the degree of confidence that we are accurately measuring impact, and we anticipate this will be a vigorous point of discussion among the HXP measurement subcommittee members. We also want to incorporate outcome measures that focus on either desirable health states (independent living status) or elimination of undesirable health events (hospitalization). In addition, where possible, the given metrics should be already available or relatively easy to obtain (to keep audit and tracking costs to a minimum).

Finally, it is our belief that while the CHI is the appropriate measure to assess health system improvements, the actual solutions created by competing teams should improve individual health status. Therefore, the HXP endeavors to create a third measure, called the Individual Vitality Score (IVS), that will measure the degree of health activation, proactive health improvement, and/or health literacy adjusted for age, sex, morbidity, and genetic risk. Given our current systems orientation toward disease care, we believe that reorienting the system toward
improving individual “vitality” would yield dramatic changes in reimbursement methods, prevention focus, and behavorial changes. The IVS will serve as a catalyst to transform our current current perspective of heath (“absence of disease”) to the invigorating and progressive concept of vitality. We believe that creating the IVS can revolutionize the way individuals, providers, and health systems think about managing a “health portfolio” (think health streaming), including the creation of individual health action plans that optimize health assets over time.

Developing these three metrics - HCV, CHI, and IVS - will require careful thought, analytical integrity, and skillful compromise. We believe that the creation of the IVS will encourage teams to develop meaningful innovation in promoting vitality. Measuring HCV and creating a CHI will require detailed analysis, particularly given the role each will play in judging the HXP competition. Given that the CHI is a component of the overall HCV measure, it is logical to begin our measurement conversations around the creation and validation of a new CHI.

We have begun to evaluate traditional measures of community health, including a) functional health pass rate (e.g., fitness test, % ambulatory, % living independently), b) ER visits, c) hospitalizations/ 30 day re-hospitalizations, d) Major morbidity/ disability, e) sick days taken, f) perceived health score, and g) patient experience and will be validating these ideas in an upcoming meeting with our Measurement Subcommittee in New York City on June 9-10.

We are actively seeking input and guidance from our HXP measurement subcommittee and others in the development of these three measure. We look forward to your feedback.

* Much of the CHI concept was based on excellent work by the Dartmouth Health Policy and Clinical Research Team.
Anonymous said...

It might be interested to see how people and communities score now as well as what percentage of health is really under our control.

We all know the impact of lack of exercise and obesity but data alone doesn't become knowledge nor change behavior. People who smoke are well aware of the risks to their health but continue.

We all wish that telling people their numbers would somehow result in different behavior but that fails to grasp the complex intervention that is required for behavior change. Even if everyone was to stop smoking, maintain a healthy diet (assuming they can afford it) and exercise how much of health care costs would be reduced?

Most studies show that 10% of people with chronic conditions account for 70% of the costs so why not start there instead? Seniors should be the target not the healthy wealthy.

Scott Shreeve, MD said...

Anonymous,

You make a great point which I probably did not highlight enough in the measurement. The top 5% of patients are responsible for ~50% of expenses. If we were to go after just those patients, we could begin to "bend the curve."

However, I believe it is the people under the "long tail" part of the curve that we can also begin to impact as well by changing the culture of health and our notions of health. This is obviously a longer slog - and fortunately - 50% of people are not costing us too much money right now which gives the education an opportunity to have an impact.

I share your opinion that highlighting the facts won't change behaviors (smoking is a great example). However, I also believe that tying those bad behaviors to their real financial costs will (Safeway Health is a great example of this!)

Tim Richardson, PT said...

Facts won't change peoples' behavior but feedback of performance will let those motivated to change obtain knowledge of results.

The motivation to change might be government payments for higher performance scores.

The payments could be in the form of tax credits.

The technology exists to measure many of the validated self-report measures by e-mail sent directly to the individual.

"Health" is a poorly defined construct that has a low present value to the majority of Americans.

"Sickness" is currently the driver of demand for our health care market.

Could some government stimulus be directed to tax credits for healthy, measurable improvements in self-report and performance scores on the IVS?

Tim
TimRichPT@PhysicalTherapyDiagnosis.com
www.PhysicalTherapyDiagnosis.com

ASpolarich said...

This is a lot like taking a huge Economics 301 Final Exam. There are so many variables to discuss, variables to define and other items that must be measured. The X Prize program seems aware of these challenges, however, there still needs to be more discussion on the meaning of 'value'. How will people spend their health care dollars in this economy in an attempt to better the health value in their community? Will they participate? Are they altruistic at all? Will they become more empathic as the recession abates?

These and other questions are some we considered in doing the Spectrum Health Value Study. Results of our preliminary findings can be found at www.healthvaluestudy.com. Also, we were just accepted for an oral presentation at the APHA meeting in Nov in Philly. You can follow us on Twitter at HealthValue.

Scott Shreeve, MD said...

Audrey,

Thanks for your input. We are finding that part of the "good fight" is to help educate individuals around what health value actually means and what health outcomes we should be wanting to achieve.

We want people to be guided, advised, or steered to providers who deliver high quality outcomes at low costs. We want people to understand that they can and should be accountable for their own health and behaviors. We would love to see health payment be utilized to reward best choices by patients, providers, and others within the system.

I will look forward to reading your information on health value.

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