IDENTIFYING KEY AREAS FOR DELIVERY SYSTEM RESEARCH

The Challenge and Promise of Delivery System Research: A Meeting

of AHRQ Grantees, Experts and Stakeholders

Lawrence Casalino M.D., Ph.D.Weill Cornell Medical College

Sterling, VA February 16, 2011

This talk - a quick overview:

• what is delivery system research?

• conceptual model• criteria for selecting key areas for delivery system research

• four key areas and research questions

• ARRA grantees2

Why study the delivery system?

• patients, legislators, the media, physicians mostly don’t see a problem

But:

• the discoveries of basic scientific and clinical research do not help patients unless they are effectively used in the delivery system.

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What is delivery system research?

• focuses on organizations that provide health care

and/or

• inter-relationships among these organizations

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Generic model of an organization and its

incentives EXTERNAL INCENTIVES CULTURE; LEADERSHIP STRUCTURE PROCESSES OUTCOMES PATIENT ENGAGEMENT

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Criteria for selecting key areas for delivery system research (1)

• will this research help patients—either directly or by helping providers to provide better care? (Clancy)

• does this research have potential for a major impact on the population as a whole or on subgroups? (IOM)

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Criteria for selecting key areas for delivery system research (2)

• focuses on areas emphasized by the health reform law

• studies both intended and unintended consequences

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Criteria for selecting key areas for delivery system research (3)

• Objective: to get providers into high performing organizations and give these organizations incentives to continually improve care for their population of patients - therefore: – identify types of organizations that tend to be high performing

– identify incentives likely to lead to creation of these organizations and to movement of providers into them

– identify incentives for organizations to improve care

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Major gap in research and funding:

• focus mainly on processes of care, particularly intraorganizational processes

• this is important, but difficult to generalize, because:– process effectiveness depends on the way it is implemented and on the context within which it is implemented

– most attempts to improve care involve multiple processes; how do we know which are important?

• also, organizations unlikely to adopt a process unless they have adequate incentives to do so

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Qualifications/limitations

• just my opinions - no compelling evidence

• somewhat arbitrary choices - even with agreement on criteria, many choices are possible

• see the “long list” and the rest of the “short list”

• see the reasons given for selecting these areas

• better to be provocative and wrong than to be too general

• key areas likely to change over time10

Key research area #1

• analyses of the demographics of the delivery system—i.e., of each component of the conceptual model

• and of relationships among the components of the model

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Why?

• knowing the demographics is an essential first step, which would make it possible to study in a generalizable way the inter-relationships outlined in the conceptual model between structure, incentives, processes, and outcomes

• huge gaps in knowledge

• very little funding available for this

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Examples of research questions

• which type of medical group performs better:– small, medium, large?– single specialty or multispecialty?– hospital or MD-owned?

• is the percentage of physicians employed by hospitals increasing? If so:– why?– is this a good thing?

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Key research area #2

• analyses of ways to structure incentives so that they lead to:– desirable changes in the demography of organizations in the delivery system

– continual efforts by these organizations to improve the health of their populations of patients

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Why?

• incentives likely to be critical

• despite funding, we are far from having definitive answers

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Examples of research questions

• compare the effects of different payment methods on quality, costs, and the demography of the delivery system

• how can undesirable unintended consequences of external incentive programs be minimized?

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Key research area #3

• how can performance measurement be improved?

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Why?

• hard to improve what you can’t measure

• we often measure less, rather than more, important things

• increased reliance on external incentives (e.g. P4P, public reporting, “shared savings”) measures had better be good

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Examples of research questions

• at what level is it desirable and feasible to measure quality (e.g. individual MD, medical group, accountable care organization)?

• how much weight should be given to patient experience in evaluating quality?

• how can electronic medical records be used to measure performance?

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Critical research area #4:

• Analyses of interprovider/interorganizational processes for improving care

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Why?

• may be a major source of poor quality/poor patient experience/high costs

• little is known about this area

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Examples of research questions

• can small practices effectively share resources (e.g. nurse care managers)?

• how valuable is phone communication among physicians about patients (even when patient is not referred)? If valuable, how can it be encouraged?

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AHRQ ARRA CER Grantees

• lack time to do this any sort of justice

• 4/6 evaluation grants and 4/4 demonstration grants can be categorized as falling into the key areas suggested here

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