By Yoshimi Anzai, MD, MPH, Chief Medical Quality Officer and Professor of Radiology at the University of Utah Health Sciences
There is increasing pressure in the United States to reduce health care expenditures and improve quality of care. The U.S. Department of Health and Human Services announced the goal that 30% of Medicare payments would be tied to quality of care by the end of 2016 and 50% by the end of 2018. Such alternative, value-based payment models incentivize efficient, effective and coordinated care at a lower cost by shifting the financial risk from payers and insurers to hospitals and providers. One of the biggest challenges for a health care system to improve value – as generally defined by outcomes over cost - is the lack of understanding of the cost of care delivery. For an alternative, value-based payment model to succeed in reducing expenditures and improving outcomes, physicians must have a deep understanding of actual care costs and defined outcomes for each medical condition or procedure.
Under the holistic vision and leadership of Dr. Vivian Lee, Senior Vice President of University of Utah Health Sciences, CEO of University of Utah Health Care and Dean of the University of Utah School of Medicine, a multidisciplinary team created a pragmatic and actionable analytics tool for understanding and measuring value in health care. This value analytics framework is known as VDO (Value Driven Outcomes). VDO draws information from the enterprise data warehouse, which includes clinical care data; nationally-defined and clinician-defined quality metrics; costs associated with supply, pharmacy and imaging, as well as laboratory and human resource utilizations; and the general ledger of all financial expenses. VDO analytics merge detailed financial information with clinical measures for each provider at the individual patient encounter level. VDO is designed around a central principle of modularity and scalability – taking every specific cost recorded in the general ledgers of the health system and the School of Medicine and attributing them to direct patient care. These direct patient care costs are reconciled to individual patient utilization and then attributed to each patient encounter.
To make impactful changes in care delivery, an executive decision was made to bring the VDO data analytics tool to the hands of the frontline providers. The goals of the implementation of the VDO tool in the academic health care enterprise are to inform physicians of cost, quality, and outcomes of patient care and to facilitate clinical care design innovation. The results of the initial clinical implementation were just published (reference1).
The VDO Explorer is the self-exploratory tool that visualizes the levels and variability of cost of care for a given clinical condition or procedure, and also enables stratified analysis for specific cost categories, such as pharmacy, supply, laboratory and imaging tests, or facility costs with respect to peer physicians (reference 2). Furthermore, the VDO Explorer allows providers to dive deeper into the data and question what accounts for the variations, by displaying the amounts of the top cost drivers of individual categories. As such the VDO Explorer allows the provider to identify opportunities to reduce cost of care as well as care variations. A key principle in these inquiries is to ensure the sustainability or ideally, improvement of clinical outcomes in reference to cost-containment efforts.
To strategically allocate the institutional resources at the University of Utah, we have identified the Top 50 Medical Conditions (MC) for priority value improvement based upon the volume, financial impact, required national quality measures of external entities, including CMS, UHC (United Health Consortium, now called Vizient), and NQF (National Quality Forum). Within the Top 50 Medical Conditions, our organization is focused on improving the value of the twelve conditions /procedures that are either (i) acute inpatient care conditions with high mortality, or (ii) high-volume and high-cost surgical procedures. These twelve conditions are 1) sepsis, 2) pneumonia, 3) induction labor, 4) lumbar spine fusion, 5) cervical spine fusion, 6) joint replacement, 7) rotator cuff repair, 8) stroke, 9) hip fracture 10) heart failure, 11) CABG (coronary artery bypass grafting), and 12) TAVR (trans-aortic valve repair).
Development of the VDO scorecard for the Top 50 Medical Conditions is truly a team effort, empowering physician champions, physician assistants, nurses, pharmacists, care managers, and other members of the care team to define how high-value care should be delivered to our patients. VDO scorecards incorporate relevant quality metrics and disease-specific outcomes as well as the average cost of care. Essential quality and outcome variables are combined into a single binary measure called “perfect care” (PC). The definition of PC is unique to each medical condition and driven by physician champions and the care team. For example, mortality is an important measure for CABG, but not useful for joint replacement due to its extreme rare occurrence. If a continuous variable is used, we apply an evidence-based threshold, such as mechanical ventilation following CABG within 24 hours or antibiotics given to pneumonia patients within 2 hours, for example. PC is a composite of the quality metrics and condition-specific outcomes that providers believe are most impactful for patients’ outcomes. PC is achieved only when all metrics are met. The average cost and percentages of patients who achieved “perfect care” is tracked either monthly or quarterly.
VDO identifies variations of care and cost outliers, as well as opportunities for quality improvement. For example, VDO identified supply cost variations among several surgeons performing similar joint replacements or spine fusion procedures. For hospitalists, VDO indicated largest variation of care for laboratory utilization. With support from the process engineers, standardized value driven care pathways were developed for complex medical conditions, such as sepsis, pneumonia, or hip fracture. These value-driven care pathways reduce care variations and improve outcomes.
The cost data on VDO is also being extended to include the cost of the full cycle of care, which is currently defined as three days before admission to 90 days post discharge. The cost and outcome assessment of the full cycle of care gives us an opportunity to establish better coordination of care and to deliver optimal results while also preparing for future bundled payment models where healthcare systems are held accountable for high-value care.
Encounter-specific costing data opens unique opportunity to identify patients with extremely high costs (e.g., those patients with costs that are more than two or three standard deviations above the average). Identifying specific clinical, social, behavioral, and genetic factors associated with “cost outlier” patients offers an opportunity for intense health management using the predictive analytics. If we can identify particular risk factors that predict poor clinical outcomes and a high cost of care, proactive measures can potentially be taken to address underlying risk factors. Taken together, our health sciences investigators believe the VDO tool can help population health locally, regionally, and nationally.
The impact of VDO reaches beyond hospital operations and clinical delivery. It provides a great opportunity for comparative effectiveness research in real clinical settings. With proper risk and severity adjustments, the cost of care and relevant outcomes can be compared across patients receiving two or more different procedures or medications. Furthermore, disease-specific and patient-reported outcomes (PROs) are tracked longitudinally to determine the impact of various clinical interventions from patients’ perspectives. Incorporating PROs into the VDO dashboards gives us a comprehensive view of care from patients’ perspectives.
For data analytics to positively impact the delivery of care, three elements are essential, 1) physician engagement, 2) actionable data, and 3) team building for specific medical conditions. Physician champion(s) for each medical condition lead the value improvement efforts. Although the VDO data analytics present incredibly powerful information, physicians have to be in the driver’s seat of the value improvement journey to redesign and innovate care. The multidisciplinary team, including administrative partners, process engineers, business intelligence experts, and quality consultants support our providers in this value improvement process. We also offer Value Improvement Leadership training for practicing physicians. This 13-week course, taking place twice a year, offers didactic lectures, self-learning activities, and coaching.
VDO offers an opportunity for value improvement in the real clinical settings, while providing opportunities for impactful health services research. The tool has tremendous potential to transform health care delivery. VDO can only make a positive impact when providers and their teams combine their expertise to implement care innovation to achieve better outcomes. Health care transformation is complex and messy. Although there is a long journey ahead of us, the VDO tool and our associated value improvement framework are enabling our exciting journey of health care transformation.
- Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality. Lee VS, Kawamoto K, Hess R, et al. JAMA 2016: 316(10): 1061-1072
- Value Driven Outcomes (VDO): a pragmatic, modular, and extensible software framework for understanding and improving health care costs and outcomes. Kawamoto K, Martin CJ, Williams K, et al. (2015). J Am Med Inform Assoc. 22:223-35. (the technical details of VDO and evaluation)