REPORT TO THE PRESIDENT BETTER HEALTH CARE AND LOWER COSTS: ACCELERATING IMPROVEMENT THROUGH SYSTEMS ENGINEERING
In recent years there has been success in expanding access to the health-care system, with millions gaining coverage in the past year due to the Affordable Care Act. With greater access, emphasis now turns to guaranteeing that care is both affordable and high-quality. Rising health-care costs are an important determinant of the Nation’s fiscal future, and they also affect the budgets for States, businesses, and families across the country. Health-care costs now approach a fifth of the economy, and careful reviews suggest that a significant portion of those costs does not lead to better health or better care.
Other industries have used a range of systems-engineering approaches to reduce waste and increase reliability, and health care could benefit from adopting some of these approaches. As in those other industries, systems engineering has often produced dramatically positive results in the small number of health-care organizations that have implemented such concepts. These efforts have transformed health care at a small scale, such as improving the efficiency of a hospital pharmacy, and at much larger scales, such as coordinating operations across an entire hospital system or across a community. Systems tools and methods, moreover, can be used to ensure that care is reliably safe, to eliminate inefficient processes that do not improve care quality or people’s health, and to ensure that health care is centered on patients and their families. Notwithstanding the instances in which these methods and techniques have been applied successfully, they remain underutilized throughout the broader system.
The primary barrier to greater use of systems methods and tools is the predominant fee-for-service payment system, which is a major disincentive to more efficient care. That system rewards procedures, not personalized care. To support needed change, the Nation needs to move more quickly to payment models that pay for value rather than volume. These new payment models depend on metrics to identify high-value care, which means that strong quality measures are needed, especially about health outcomes. With payment incentives aligned and quality information available, health care can take advantage of an array of approaches using systems engineering to redesign processes of care around the patient and bring community resources, as well as medical resources, together in support of that goal.
Additional barriers limit the spread and dissemination of systems methods and tools, such as insufficient data infrastructure and limited technical capabilities. These barriers are especially acute for practices with only one or a few physicians (small practices) or for community-wide efforts. To address these barriers, PCAST proposes the following overarching approaches where the Administration could make a difference:
- Accelerate alignment of payment systems with desired outcomes,
- Increase access to relevant health data and analytics,
- Provide technical assistance in systems-engineering approaches,
- Involve communities in improving health-care delivery,
- Share lessons learned from successful improvement efforts, and
- Train health professionals in new skills and approaches.
Through implementation of these strategies, systems tools and methods can play a major role in improving the value of the health-care system and improving the health of all Americans.
Summary of Recommendations
Recommendation 1: Accelerate the alignment of payment incentives and reported information with better outcomes for individuals and populations.
1.1 HealthandHumanServices(HHS)shouldconvenepublicandprivatepayers(includingMedicare,Medicaid, State programs, and commercial insurers) and employers to discuss how to accelerate the transition to outcomes-based payment, promote transparency, and provide tools and supports for practice transformation. This work could build on current alignment and measurement-improvement efforts at the Center for Medicare and Medicaid Services (CMS) and HHS broadly.
1.2 CMS should collaborate with the Agency for Healthcare Research and Quality (AHRQ) to develop the best measures (including outcomes) for patients and populations that can be readily assessed using current and future digital data sources. Such measures would create more meaningful information for providers and patients.
Recommendation 2: Accelerate efforts to develop the Nation’s health-data infrastructure.
2.1 HHS should continue, and accelerate, the creation of a robust health-data infrastructure through widespread adoption of interoperable electronic health records and accessible health information. Specific actions in this vein were proposed in the 2010 PCAST report on health information technology and the related 2014 JASON report to the Office of the National Coordinator for Health Information Technology (ONC).
Recommendation 3: Provide national leadership in systems engineering by increasing the supply of data available to benchmark performance, understand a community’s health, and examine broader regional or national trends.
3.1 HHS should create a senior leadership position, at the Assistant Secretary level, focused on health-care transformation to advance information science and data analytics. The duties for this position should include:
- Inventory existing data sources, identify opportunities for alignment and integration, and increase awareness of their potential;
- Expand access to existing data through open data initiatives;
- Promote collaboration with other Federal partners and private organizations; and
- Create a more focused and deep data-science capability through advancing data analytics and
- implementation of systems engineering.
3.2 HHS should work with the private sector to accelerate public- and private-payer release of provider-level data about quality, safety, and cost to increase transparency and enable patients to make more informed decisions.
Recommendation 4: Increase technical assistance (for a defined period—3-5 years) to health-care professionals and communities in applying systems approaches.
4.1 HHS should launch a large-scale initiative to provide hands-on support to small practices to develop the capabilities, skills, and tools to provide better, more coordinated care to their patients. This initiative should build on existing initiatives, such as the ONC Regional Extension Centers and the Department of Commerce’s Manufacturing Extension Partnership.
Recommendation 5: Support efforts to engage communities in systematic health-care improvement.
care quality and overall value.
5.2 Future CMS Innovation Center programs should, as appropriate, incorporate systems-engineering
principles at the community level; set, assess, and achieve population-level goals; and encourage grantees
to engage stakeholders outside of the traditional health-care system.
5.3 HHS should leverage existing community needs assessment and planning processes, such as the
community health-needs assessments for non-profit hospitals, Accountable Care Organization (ACO) standards, health-department accreditation, and community health-center needs assessments, to promote systems thinking at the community level.
Recommendation 6: Establish awards, challenges, and prizes to promote the use of systems methods and tools in health care.
6.1 HHS and the Department of Commerce should build on the Baldrige awards to recognize health-care providers successfully applying system engineering approaches.
Recommendation 7: Build competencies and workforce for redesigning health care.
7.1 HHS should use a wide range of funding, program, and partnership levers to educate clinicians about
systems-engineering competencies for scalable health-care improvement.
7.2 HHS should collect, inventory, and disseminate best practices in curricular and learning activities, as well as encourage knowledge sharing through regional learning communities. These functions could be accomplished through the new extension-center functions.
7.3 HHS should create grant programs for developing innovative health professional curricula that include systems engineering and implementation science, and HHS should disseminate the grant products broadly.
7.4 HHS should fund systems-engineering centers of excellence to build a robust specialty in Health-
Improvement Science for physicians, nurses, health professionals, and administrators.