As the US Senate debates revisions to the Affordable Care Act this week, people on both sides of the aisle are asking how to improve the healthcare industry. Faced with the reality that the major political parties are entrenched opponents, one wonders whether social collaboration to improve healthcare could emerge in other ways. It is a question I had taken up before, when I asked myself whether organizations across the healthcare value chain could be incentivized by transparancy and reputation to optimize healthcare outcomes. Would leaders reform their organizations if they were graded publicly? From song rankings on the Billboard Charts to credit scores by Moody's or Standard and Poor's, we can see that ratings matter. Could the rating of healthcare organizations change behavior?
Specifically, could maturity assessments improve outcomes? In other words, could a health system innovation maturity model be created that motivates healthcare organizations to develop and use capabilities that improve population health, population healthcare, and the innovation of both? Buoyed by this question, four years ago I waded into the deep waters of US healthcare reform through a multi-million dollar grant proposal to establish a Congressional award based on maturity assessments (Figure 1). My idea was that a highly esteemed national award based on detailed assessments and summarized as scores or ratings could "pull" innovation from organizations to improve outcomes in creative and unpredictable ways that nobody could "push" or require organizations to innovate.
Measurement is known to change behavior. Evaluation frameworks are self-fulfilling because they shape institutional designs and management practices as well as social norms and expectations about behavior, thereby creating the behavior that they predict (Ferraro, Pfeffer, Sutton, 2005; Biggs, Bearman, Hedstrom, 2009). For evaluations of healthcare organizations to inspire change, they would need to be based on standards endorsed by the major stakeholders. We proposed to establish standards focused on population health outcomes endorsed by Medicare and Medicaid.
Specifically, we proposed to encourage helping the following:
o Age groups: prenatal to age 2, ages 2 -12, young adults (13-19), adults ( 20-64), and seniors (65+)
o Population insurance status: Uninsured; Commercially Insured; Medicaid/CHIP; Medicaid; Other.
The mechanism is to develop and support dialogue and actions aimed at population health management goals, namely improved health, improved healthcare, cost savings (for the patient – not utilization-based cost savings), better access, and patient satisfaction.
If healthcare organizations were assessed on their ability to innovate population healthcare and improve population health in ways that enact these goals, what kinds of innovations might they conceive? Healthcare innovation projects could take the form of vouchers and privatization that decentralizes the system and removes unnecessary burdens from business. Innovation projects that enable out-of-pocket payment (OPP) by consumers for routine medical care could transform the system from one dominated by third party payers toward a model that would put consumers in charge of their healthcare dollars, unleashing market disciplines into the equation for the first time. Public-private partnership projects could work to reform licensing requirements for medical schools, hospitals, pharmacies, and medical doctors and other health-care personnel, causing prices to fall and a greater variety of healthcare services to appear on the market. Or insurance products could be developed to protect against events over whose outcome the insured possesses no control; a big problem in health insurance is if you are on your own or part of a very small group, you have no leverage for prices, and if someone gets very sick, then you don’t have the protection of thousands or even hundreds of thousands of people sharing the risk, but employers could band together in associations that let individuals join to buy health insurance as a group to cover high risks or even pre-existing conditions. Alternatively, innovation could address the production and sale of pharmaceutical products and medical devices. Whatever the innovations may be, the organizations responsible would be assessed and scored for innovation directed at improving population health and healthcare. Innovations would be evaluated for efficacy, and the ability of organizations to deliver the innovations would be characterized. Seeing clearly which organizations are actually working for the greater good (and whose good works are indeed working), consumers could make more discriminating healthcare choices.
I was lead scientist, research group leader, and the principal assessor and improvement consultant for participating healthcare organizations (Figure 2). Despite partnering with Emory University and Suffolk University and lobbying Tom Price (who has since become the US Secretary of Health and Human Services), we were unable to enroll the Centers for Medicare & Medicaid. Yet I remain convinced that something akin to the Malcolm Baldrige National Quality Award would be a creative and low-cost way to encourage providers to improve health outcomes for individuals. Payers, providers, producers, fiscal intermediaries, and accountable care organizations would be assessed, ranked, and awarded publicly, creating ratings with financial implications.
What do you think? Do you believe that reputation mechanisms like maturity assessments, awards, and ratings can motivate organizations across the healthcare value chain to improve outcomes (quality of life years or QALYs) for individuals? Do you believe the people running healthcare organizations could be motivated to collaborate on healthcare innovation across the value chain if their reputations were at stake?