How Will Accreditation of Your Ambulatory Endoscopy Center Be an Essential Component of Showing Value-Based Health Care?

Abstract

That health care in the United States is in a state of crisis has become undeniable. Participants at all levels of the system are fed up with the status quo. Meanwhile, health care has grown into a full-fledged industry, representing a significant proportion of the national economy. The failure of this industry to control costs, or at least to show improved outcomes for patients, has caused providers, suppliers, and payers to become the target of increasing frustration from the rest of society. As costs spiral to unsupportable levels, players external to the health system, namely from the business community, are now weighing in with their own perspectives on the crisis and how to fix it. One approach that has been gaining significant traction is value-based purchasing, a business management concept already used in many other industries. The application of value-based purchasing to the United States health care system has been most fully articulated in the work by Porter 1Porter M.E. A strategy for health reform—toward a value-based system.N Engl J Med. 2009; 361: 109-112Crossref PubMed Scopus (649) Google Scholar and Elizabeth Teisberg, business school professors at Harvard University and the University of Virginia. These investigators essentially aim to restore the standard rules of economics to the health care market. Simplistically, an open market makes information regarding the quality of products and services readily available to purchasers, who generate demand for these goods. The willingness of rational purchasers to pay, based on supply, establishes a market price. Producers compete to improve quality and lower costs. In their seminal 2006 book, Porter and Teisberg 2Porter M.E. Teisberg E.O. Redefining health care: creating value-based competition on results.in: Harvard Business School Press, Boston, MA2006: 111Google Scholar illustrate the myriad ways in which health care has failed to conform to rational and efficient market dynamics and specify 8 core principles that underlie the transition to a value-based system of the future. The cornerstone of value-based health care is that the entire health care system must shift its focus to value rather than costs. Value in health care is the quality of patient outcomes relative to dollars spent. Value is assessed from the patient's perspective, not that of physicians, hospitals, health plans, or employers. It derives ultimately from improved health outcomes for patients. The dysfunction of the current health care system arises in large part from an overemphasis on costs, and the creative ways that each player in the system devises to shift these costs onto other players. Much of the angst in public discussions of the current health care system focus on the amount being spent, often expressed as a percentage of the gross domestic product. Such arguments are meaningless in value-based health care. After all, why should a wealthy society not spend more on providing its citizens with longer, healthier lives, as long as other basic needs are being met? The key is whether increased expenditures actually result in improved health outcomes. Value-based health care is rooted firmly in capitalist principles, in which competition between individual players in the system drives innovation and increased productivity. The current system, however, sets up zero-sum competition based on total costs; the rational impetus for each player in the system to improve their own financial performance can come only at the expense of others. Health plans gain by shifting costs to patients. Government programs reimburse providers at levels that are often lower than cost; providers then shift these costs by charging higher fees to patients with private insurance. In a value-based system, providers compete based on the measured outcomes of their patients. Those providers with the best outcomes will capture more business. Rather than trying to find new ways to maximize profit by shifting costs, providers will focus their attention on providing the most cost-effective care for their patients. A competitive system based on results will be much more effective in improving cost effectiveness than the current model of trying to second-guess physicians' decisions and constraining patients' choices. As described, value in health care is assessed from the patient's perspective. The patient is concerned with achieving the best outcome for a specific medical condition, and over the full cycle of care. The current system is fragmented by physician specialty and the specific procedures performed. A value-based model envisions providers aligned not by subspecialty or by a focus on individual services, but instead on specific medical conditions. Such provider teams then will be able to document outcomes over the full cycle of care for those conditions. The productivity frontier is an economic concept that illustrates the trade-off between increased quality and increased cost, assuming a mature and efficient market. At present, however, the health care market falls far short of such efficiency, and as such currently operates well below the productivity frontier. Therefore, increases in quality in many cases actually will result in lower costs. Implementing systems to reduce errors in medicine, for example, will improve health outcomes and reduce overall costs. Arguably, as best practices rapidly disseminate in a competitive, value-based system, health care costs will significantly decrease. As Porter and Teisberg put it, “value in health care delivery is created by doing a few things well, not by trying to do everything.” 2Porter M.E. Teisberg E.O. Redefining health care: creating value-based competition on results.in: Harvard Business School Press, Boston, MA2006: 111Google Scholar They envision a market in which providers focus on providing full-cycle care for specific medical conditions. Such specialization drives efficiency and innovation, and providers who specialize in this way will be able to compete more effectively and gain higher patient volumes. Scaling and experience allows such providers to develop specialized care teams and to build dedicated facilities. This will lead to higher quality outcomes, improved efficiency, and lower prices. The ambulatory endoscopy center exemplifies such an approach. Providers currently tend to limit their competitive efforts to very narrow geographic areas. This promotes fragmentation, impedes concentration of experience and patient volume, and, ultimately, undermines value. In our increasingly mobile society, many patients may be willing to travel longer distances to seek out providers who can show increased experience and better outcomes. The size of the geographic market in which a provider may compete will increase with the degree of specialization required. For highly sophisticated care, such as organ transplant, competition at a national or even international level may be most desirable. Competition based on results hinges on the widespread availability of such information in a format that is comprehensible to patients. Health plans can play an important role in collecting and disseminating such information, a trend that already is happening in many areas. Results information must be clinically relevant and meaningful. Ideally, it should focus on patient outcomes, and be appropriately risk-adjusted. Current quality initiatives focusing on process measures are misguided. Although an unhurried, careful examination during screening colonoscopy is desirable, the relevant outcome is the provider's effectiveness in detecting polyps and preventing colon cancer, not the amount of time spent withdrawing the scope. Appropriate outcomes measures are lacking in many areas of medicine, including gastroenterology. Professional societies naturally should play a critical role in establishing such measures, and the American Gastroenterological Association Institute already has taken the lead in this area. However, should physicians prove unwilling or unable to achieve consensus on appropriate measures, it is a virtual certainty that other players will quickly fill the vacuum with their own measures. Value-based competition will spur innovation in all areas of the health care system: new methods, new facilities, new organizational structures, new processes, and new forms of collaboration between providers. Such innovation is necessary if the nation's health care system is to address the needs of its aging population without rationing services or incurring huge cost increases. Accreditation has become the principle mechanism by which endoscopy centers can show a commitment to high-quality care and compliance with nationally accepted standards. Currently, 3 widely recognized options exist for ambulatory endoscopy centers seeking accreditation: the Accreditation Association for Ambulatory Healthcare, the Joint Commission, and the American Association for Accreditation of Ambulatory Surgery Facilities. All 3 accrediting bodies follow a similar process. Organizations seeking accreditation must complete a written application and undergo periodic on-site surveys to assess compliance with published criteria. These accreditation standards differ between the 3 bodies, but generally focus on structure and process variables. They attempt to ensure that accredited organizations have an organizational structure and governance that provides proper oversight, sufficient facilities and equipment, appropriately trained providers, and established policies and procedures to ensure safe and high-quality endoscopy. Increasingly, accreditors also are seeking evidence of high-quality patient outcomes through requirements for benchmarking and ongoing quality-improvement activities. All 3 accrediting bodies have programs for both office-based facilities as well as licensed ambulatory surgery centers; generally, the standards for accreditation do not differ between these 2 types of organizations. Where permitted under state law, accreditation by one of these bodies also serves as certification for Medicare under the deemed-status program, with the addition of certain Medicare-specific standards. At first glance, ambulatory endoscopy centers (AECs) may not appear to fit into the model for a value-based health care system as envisioned by Porter and Teisberg. 2Porter M.E. Teisberg E.O. Redefining health care: creating value-based competition on results.in: Harvard Business School Press, Boston, MA2006: 111Google Scholar By focusing on a single class of diagnostic and treatment services, AECs do not encompass the full cycle of care for most digestive conditions. Certainly, the hospital industry has lobbied stridently against specialized providers, such as specialty hospitals and ambulatory surgery centers, complaining that they cherry pick only the healthiest patients. Porter and Teisberg 2Porter M.E. Teisberg E.O. Redefining health care: creating value-based competition on results.in: Harvard Business School Press, Boston, MA2006: 111Google Scholar argue, however, that this is exactly what should happen to maximize efficiency and value. Why should healthy patients not be cared for in less-intensive, less-costly settings? AECs epitomize such efficiencies in the provision of endoscopy services. By participating wholeheartedly in the accreditation process, AECs show the ability to provide the highest quality care in the most cost-effective manner. As gastroenterologists increasingly participate in the publicly recognized quality standards required to achieve accreditation, value for gastroenterology patients is improved. The development of value-based competition is promoted by the accreditation process. Accreditation increasingly is recognized as a marker for organizations that are committed to providing high-quality health care. Accredited AECs may use this achievement to competitive advantage in the value-based model envisioned by Porter and Teisberg. 2Porter M.E. Teisberg E.O. Redefining health care: creating value-based competition on results.in: Harvard Business School Press, Boston, MA2006: 111Google Scholar Because accreditation requires adherence to a single set of uniform standards, competition is enhanced on a regional and even a national level. Experience and scale also are rewarded because more efficient providers are more likely to have the resources, infrastructure, and organizational sophistication to meet increasingly stringent accreditation requirements. The Accreditation Association for Ambulatory Healthcare and other accrediting bodies require accredited organizations to perform benchmarking, comparing various aspects of their own operations to regional and national databases. Currently, available comparative data are concentrated mainly on financial and process-oriented variables. However, as noted, the American Gastenterological Association Institute and other organizations are working to develop and validate true outcomes measures specific for gastroenterology. To the extent that these measures include endoscopy outcomes, they will be very useful for showing patient value for AECs. The accreditation process has become progressively focused on measurement; in addition to the benchmarking activities described earlier, accredited organizations also are required to conduct regular quality-improvement studies. Such studies typically focus on rectifying identified problems in a center's operations. They are expected to conform to a cyclic process, in which data are collected to delineate the source and frequency of the identified issue, intervention is made to address the problem, and additional data are collected to confirm improvement. As these organizations continue to participate in the re-accreditation process, they are expected to develop increasing sophistication in performing continuous quality-improvement activities. Ultimately, accredited AECs will need to measure actual endoscopy results, such as adenoma detection rates. Once such results information is provided in a meaningful way for prospective patients, value will be increased dramatically. This is viewed as a critical step by proponents of value-based health care and other players. The measurement and reporting of outcome measures will soon become mandatory. AECs that proactively refine their measurement capabilities through participation in accreditation likely will enjoy significant advantages. Today, value-based health care may sound like just another catchy buzzword. Certainly, the evolution of health care in the United States may not conform exactly to the vision outlined earlier. Given the profound external forces at work on our industry, however, it is certain that gastroenterologists as well as other providers increasingly will be forced to show that their services provide real value to patients. Accreditation is and will be an important mechanism to promote AECs in this value-based system.