Quality Is the "New Currency in Healthcare Delivery," UVA's Shannon Tells PQA

When President Lyndon B. Johnson signed the law that created Medicare more than 50 years ago, there were 20 million beneficiaries, and the typical one lived just 3 years beyond age 65 and cost the government $287 a year. Today, there are 40 million beneficiaries, and the typical one lives 13 years passed age 65 and costs $8300.

With the number of beneficiaries forecast to double again over the next decade, Medicare’s costs are not sustainable without a radical rethinking of how healthcare is delivered to ensure that errors and waste are squeezed out and that the system only does things that help people, according to Richard Shannon, MD, executive vice president for Health Affairs at the University of Virginia (UVA). Shannon’s address, “Building a Culture of Quality to Transform Patient Care,” capped the opening day of the 12th annual meeting of the Pharmacy Quality Alliance, taking place in Baltimore, Maryland.

While the quality care movement has been in place for some time, it picked up steam with the Affordable Care Act (ACA) and is now entering a new phase, said Shannon, who called quality “the new currency in healthcare delivery.”

Besides the shift in demographics, Shannon said the nature of what healthcare does has shifted over a half-century. Decades ago, medicine’s chief concern was infectious disease—but vaccines and treatments have largely eradicated these threats. Today, instead of short, intense encounters with the healthcare system, patients suffer chronic disease and interact with health systems for decades—at great cost.

For some, population health has become a euphemism for shifting risk from payers to providers. Simply cutting payments to providers won’t work; eventually, it causes some providers to refuse new patients on Medicare. But doing things differently can redirect up to a third of nation’s healthcare tab—back to providers, to employers, and some to patients, he said.

“If we eliminate those things that add no value, I believe there will be sufficient resources to deliver care,” Shannon said, with affordable access for all.

He outlined 4 issues that matter going forward: (1) understanding the drivers of the delivery system; (2) understanding how public reporting shapes the agenda; (3) asking if reform can be achieved through payment reform alone; and (4) getting to the point of measuring what matters.

Not all the ways CMS has measured quality so far are fair or measuring the right things, he said. While the rise of accountable care organizations (ACOs) has helped the most inefficient systems rapidly improve, they’ve been less helpful for those already doing a good job.

And Shannon notes the reporting system has created some perverse incentives—UVA, a safety net hospital, had more than one-third of the patients who died there transferred from other hospitals last year. “They’re sending patients to us 24 hours before they die so the mortality lands on us,” Shannon said, “and I can’t tell you how many arrive in a helicopter.”

ACOs are great for “cherry picking,” Shannon said. “This movement has become a cottage industry. But is it generating meaningful data?”

So, what’s the better way?

Shannon called for an intense focus on changing processes, one that looks each day at what went wrong and asks why. It takes a team approach—involving a doctor, nurse, and pharmacist, and “lead coach.”

“Every death, every pressure ulcer, every worker injury, every event gone wrong yesterday,” Shannon said, “must be reported today and investigated today.”

The message must go from both the top down and the bottom up. “Workers have to see their leaders acting in a different way,” and they should benefit from “new tools and new skills.”

So not only will savings come from eliminating hospital acquired infections that add days to patient stays and cause more readmissions, but staff time will be saved if hospitals make sure nurses aren’t running around looking for out-of-stock items. Hospitals save money if they prevent worker injuries, and workers benefit, too.

It’s an intense approach, one that tackles a half-dozen target items at a time and focuses on them intensely until the hospital or health system masters them perfectly, Shannon said. He shared lists of items from the UVA system with dollar amounts, as well as a list of a target items that the Commonwealth of Pennsylvania had targeted for improvement, with significant improvement.

Most of all, he said, it’s essential for each health system measure things that matter—compare yourself to others, and compare yourself to yourself over time. While some obscure statistics don’t matter to the public, there are some bottom-line things the public wants to know. People who come to the hospital, want to know they're going to get better, so a hospital must be able to answer questions like, "What’s my chance of having a complication? When can I go back to work?”

According to Shannon, those were the most common questions being asked at the senior center, so UVA started answering them. By taking intense steps to improve responses to heart attacks—including giving away new equipment to emergency medical services workers—UVA reduced mortality from a heart attack from 4.13% in 2015 to 3.6% in 2016. Its rate of complications is down, too, and its 5-year survival rate for breast cancer is up. “You can use data like this to drive process improvement,” Shannon said.

Finally, he said, health systems must find ways to get understand the biggest barrier to care today: affordability. He shared the story of a woman who worked for UVA who kept ending up in the emergency department with asthma attacks. Through a program called BeWell, she told a pharmacist she could not afford the inhaler a doctor had prescribed. But she worked with that doctor, and didn’t want to admit it.

“People are struggling mightily in their lives,” Shannon said.