What can be achieved by redesigning stroke care for a value-based world?

Abstract

Stroke results in significant healthcare costs and decreased quality of life. Thoughtful healthcare delivery redesign can help solve this problem through lower-cost, higher-quality care. The dominant fee-for-service reimbursement system may not incentivize delivery systems to invest in new cost-saving delivery innovations. Furthermore, lack of transparency hinder development of new systems of care. However, emerging payment models, including bundled payments and prospective payment, promote adoption of value-based stroke care methods. Both prevention and treatment of stroke offer opportunities to improve value-for-money via adoption of a package of emerging innovations. In order to encourage such adoption, alignment of incentives is crucial.

Keywords::

• healthcare cost
• process improvement
• prevention
• stroke
• value

Possible respite from stroke-related disability & healthcare spending growth

Ischemic stroke is a large healthcare burden, with an estimated 700,000 events [1] annually in the US, costing an estimated US$22.8 billion in direct healthcare expenditures annually [1] and €18.5 billion in the European Union [2]. Stroke is the leading cause of disability in the US and the fourth leading cause of death [1]. It affects the elderly and people in their working years, with one-third of patients suffering their first stroke prior to the age of 65 [1], thus having a downstream effect of exponentially higher economic burden via indirect costs. As the population ages, the economic burden of stroke in the US is estimated to grow to US$184 billion by 2030 [1].

Healthcare delivery innovation has the potential to reduce the economic and health burden of cerebrovascular disease [3]. If designed and implemented appropriately, healthcare delivery innovations in the care of acute ischemic stroke and transient ischemic attack could have significant impact in improving healthcare outcomes and reducing the cost of care [4], thus improving the value of care we bring to patients.

Payment models

The current dominant fee-for-service reimbursement system in the US can make it challenging for physicians to do the right thing. Healthcare providers and hospitals are paid for the quantity of care they deliver, not the health of their patients.

One of the main reasons that delivery innovations is increasing is that the financial environment where physicians work is evolving. Insurers are attempting to reduce the rampant growth of healthcare expenses by testing novel ways of reimbursing for care. Earlier efforts include pay for performance where physicians managing populations of patients were financially incentivized to achieve certain health metrics, such as the Medicare Premier Hospital Quality Incentive Demonstration, have demonstrated modest impact on outcomes and quality [5] and more effective ways of nudging providers to do things the right way are being tested. Mathematical models suggest that the true financial gains are harvested only when measurable biomarkers are achieved (such as blood pressure control), not the process of screening or monitoring blood pressure [6].

The Centers for Medicare and Medicaid Services (or CMS – the largest health insurer in the US) is moving toward bundled payments and other methods of value-based payment to healthcare providers [7]. Physicians and healthcare systems will be increasingly rewarded by payers for the value they bring to patients as measured by quality outcomes and cost of care being delivered, rather than unit-based reimbursement for every encounter provided or every procedure performed. Interventions and services provided should be measured based on the outcomes of the patients, not the process of care itself.

Recommendations from a recent Presidents’ Council of Advisors on Science and Technology report also support redesigning healthcare systems and aligning payers and care providers to outcome-based health care, rather than procedure- and volume-based health care [8]. This would require harmonization of data measurement and collection to achieve accessible transparency for all parties involved: payers, providers and patients.

Savings for stroke care & improved healthcare outcomes

When we look for innovations in care delivery that have succeeded in combining upstream interventions to prevent risk factor progression, they have often been used by physician groups that bear financial risk such as Permanente’s hypertension intervention program in the US [9] or government-run programs outside the US [10].

Such innovations include individualized patient support to improve proper medication prescribing and medication adherence, moving care delivery to lower-cost settings for the lowest-risk patients and hospital- and system-wide process improvements [4]. These innovations have already demonstrated cost savings in multiple disease states such as moving from outpatient to home dialysis for end-stage renal disease patients [10] or earlier addition of palliative care services for oncologic patients [11].

They have also been demonstrated in cerebrovascular disease care, including simple ideas such as moving care for carefully-selected patients with transient ischemic attack from inpatient settings to outpatient clinic [12] or observation status [13]. The current a la carte pricing for delivery of care impacts decision-making on the location of care as the same disease condition treated in different care settings may have different reimbursements for a care delivery organization [13].

Telemedicine in stroke care has also demonstrated potential cost savings [14] but due to regulatory restrictions has had limited success in the current predominantly fee-for-service (face-to-face) model of healthcare. Hopefully as we move towards outcome-based reimbursement, this disincentive to telemedicine will be removed.

Testing the transplantability of healthcare delivery innovations created in health systems accustomed to taking accountability for population-wide health spending & care quality

Our experience in working with the US healthcare systems suggests that lack of financial incentives to improve value continues to substantially thwart motivation to adopt innovations that improve value. Moreover, if the time to recoup cost savings after implementation is long, it can be difficult to persuade administrative decision-makers to adopt a new process. Finally, clinical stakeholders accustomed to evaluation for clinical outcomes and quality improvement may forget the need to look at the financial ledger. Bringing both groups to the table requires coordination and harmonization of complex incentives.

In addition to redesigning financial incentives, physician leadership may help. Physicians maybe more accustomed to thinking about the quality outcomes of the patients in addition to the financial aspects of system changes. One such example is a physician-led accountable care organization as highlighted by a recent editorial [15] in which physicians create and work in a tightly held network to improve health in their patients and reduce hospitalizations. Aligning clinicians, administrators and payers to achieve value through innovative care delivery methods can decrease costly health events and provide high-value care when they do occur.

Future outlook

As the US moves toward new value-based methods of healthcare provider payment and physicians are encouraged to improve their patients’ health in novel ways, more health systems will be willing to adopt innovative healthcare delivery practices that allow for better healthcare outcomes at lower cost. After an extensive review of the cost–effectiveness literature, we refined a composite delivery strategy that focused on prevention of stroke and improving the efficiency of acute stroke care delivery. The authors calculated cost savings estimates and net of implementation costs of such strategies using publicly available cost data and estimated effect sizes of intervention components from peer-reviewed studies. The authors predict that with the widespread adoption of innovative stroke care delivery methods today, it is possible to effectively lower direct medical spending on ischemic stroke in the US by roughly 10% within 3 years [4].

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.