May 18, 2015 HCMatColumbia

Wrapping up the 4th Forum and planning for the next in 2016

This post is part of a series of several posts related to the 4th European Forum on Health Policy and Management: Innovation & Implementation, to be held in Berlin, Germany on January 29 and 30, 2015. For more information or to request your personal invitation contact or follow @HCMatColumbia.

Notes from the 4th Forum on health policy and management in Berlin, Germany
By Lawrence Brown, Katharina Janus, and Michael Sparer

An innovation is a (new) course of action intended to improve on the status quo. In health care, a field that overflows with self-proclaimed visionaries, innovations are a dime a dozen. Any halfway sentient being can conceive (and market) a vision and attach to it a “strategic plan” and kindred entrepreneurial accouterments. The true test of an innovation’s value is whether the changes affect improvement and whether the plan of action is indeed strategic, that is, a reliable guide from condition A to improvement B.

How these questions get answered has much to do with the identities of those who behold purported improvements. Innovations that look fine to an economist, for instance, might seem problematic to a sociologist, a political analyst, or a scholar of organizations and management. Innovations that seem to be promising in one national context might be implausible in another. Innovations that win the acclaim of health care managers may trigger complications for caregivers and vice versa.

Assessing the prospects for and progress of innovations demands breadth of view — interpretations and deliberations that incorporate a mix of disciplines, nations, and professions. Ironically, however, in health policy and management—fields that have long deplored fragmentation and hyper-specialization, and lauded at every turn the virtues of comprehensive, coordinated, holistic, integrated systems of care—fragmentation and siloing seem to dominate research, analysis, and advocacy of innovation.

The Center for Healthcare Management’s fourth Forum examined innovations and their implementation in health policy and management. To do this in a way that breaks down silos, we brought together global leaders in management practice and academics from diverse disciplines, societies, and professions in productive conversation with one another.

Relying on a traditional conference format would not have served the Forum’s purpose. Instead, the Center’s “Care-Tank” approach, relying on real-time and team-based content capturing and evaluation supported by various moderation and visualization techniques provided the opportunity to learn from others and compare notes. Conversations and interactive panels allowed participants to acquire knowledge and insights that led to fresh and promising approaches to longstanding and unresolved challenges in innovation and implementation.

David Blumenthal’s keynote on making health systems friendly for innovation explored how policymakers might be able to join forces with health system managers to create high performing health systems in the future. Later, participants pondered the conundrums of innovation from management, medical, and policy perspectives, discussing how implementation could be accomplished at the organizational level.

One central premise undergirds most efforts to encourage innovation in health care: Evidence should guide the design and alignment of incentives to advance integrated organizations, adroit in the art and science of “care management” and “population health management,” and therefore newly able to deliver better value (that is, higher quality care at less rapidly rising costs).
Forum participants then zeroed in on five key challenges that arise on the road to achieving this “vision.”

Beyond Technology

Today’s Western health care systems need, above all, innovations that are social in character; that is, ones that lie largely beyond the technological and clinical innovations that have preoccupied these systems heretofore.

As ever-larger numbers of citizens live into their 80s and 90s with multiple morbidities acquired decades earlier, policymakers seek to discern how best to manage these conditions (a task that requires more than just medical care) while also preventing and slowing the onset and growth of these conditions. These tasks bring to prominence both the tools of public health—healthy eating, active living, avoidance of tobacco and other drugs, and environmental safety—and the importance of larger social determinants of health (income distribution, housing, stress, job opportunities, and violence, for example).

Mastering these tasks and tools requires shifts in the professional configuration of caregiving, a kind of despecialization or demedicalization that redefines and expands the roles of primary care physicians, nurses, nurse practitioners, physician assistants and extenders, social workers, mental health providers, dieticians, coaches, therapists, navigators, community health workers, and home health aides. This re-division of labor also requires new organizational arrangements for caregiving, with innovations in payment (to and within organizations) and power among caregivers.
If these innovations in caregiving are treated not as replacements for but rather as additions to prevailing patterns of care, cost savings may be elusive. If innovations replace or diminish the activities to which providers are accustomed, savings may come at a high price in professional conflict. Either way, innovation will require strong support by political leaders, who need to maintain open minds and long-term horizons if social innovation is to be fairly evaluated.

Population Health

Successful social innovation demands extensive organizational innovation. Hospitals, including academic health centers, whose missions and finances have long centered on the delivery of acute inpatient care, have concluded that their future security depends on successfully managing large populations’ comprehensive health care needs. This has prompted admiring glances at Kaiser-Permanente, Mayo, and other “high performing” icons, which some providers seek to emulate by creating their own Accountable Care Organizations (ACOs). Whether, how often, and how well, these ACOs will build the necessary organizational culture and capacity remains to be seen.

Professional Buy-In

Effective and well-aligned financial incentives are necessary to advance these social innovations, but they are far from sufficient. Providers may resist efforts aimed at paying for value and performance, calling into question the design of measures and rewards and the extent to which they are held accountable for outcomes beyond their control. As the pace of innovation accelerates, the need for professional buy-in grows.

Deciphering The Evidence

Much of the push for innovation flows from the newfound confidence of policymakers and managers who, thanks to big data, now know how to design payment to achieve quality. But obstacles remain: Measurements can be contested. Sound calculations of the cost of care for whole episodes remain elusive. Managers who resolve to manage the data cannot always find data that tell them what to do and how to do it. And the analytical tools for assessing social innovations are far less developed than those for health technology assessment.
Before one can scientifically gauge the benefits, effectiveness, and costs of social innovations by means of random controlled trials, one needs to ask key ethnographic questions about the population(s) in question: Who are these people? How do they live? How do they view health and health care? What are their problems?

A New Generation

The most powerful driver of social innovation—a driver at once incremental and disruptive—may well be generational change. Many patients now enter the system enamored of personalized medicine, suffused with information gleaned from the internet and television, eager to share decision-making with providers, anxious about the privacy of personal information, and as intrigued by “wellness” as by highly technical medical innovation. But poverty, illiteracy, stigma, and personal and social disorganization leave no small number beyond the reach of these progressive developments.

Physicians entering practice increasingly expect to work in teams in organized settings; to be paid by a mix of salary, fees for service, bonuses, and other methods; and to be conversant with algorithms, guidelines, checklists, and other fruits of evidence-based medicine. These developments soften obstacles to integration that loomed large in the recent past. Policymakers and managers come to work confident that their command of analytical, financial, and other levers enable them to reform complex institutions.

Across Western systems, openness to, and openings for, innovation are growing. But across these systems, and across the range of innovations they contemplate—population health management, integration, value-based purchasing, evidence-based management, and more—a question nags: “Do we know how to do that”?

The “how-to” question preoccupied participants at the 4th Forum in Berlin. As one of them, Ron Kuerbitz of Fresenius Medical Care North America put it:
“These are really fundamental issues of how do we organize, how do we put the resources in the right places and what can we expect in results. So the Care-Tank’s Forum is not an academic exercise; it addresses a very practical immediate need for the changes in our system and for us to understand how we can play a constructive role in implementing these changes.”