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TABLE OF CONTENTS Preface Acknowledgements Acknowledgements Not Included Introduction I-1 to I-18 Not IncludedValue for Patients The Need to Redefine Competition Creating Value-Based Competition on Results The Structure of This Book Redefining Health Care in Practice Chapter 1: Scoping the Problem 1-1 to 1-115 Chapter 2: Identifying the Root Causes 2-1 to 2-36 Positive Sum Competition on Value Zero Sum Competition in Health Care Competition to Shift Costs Competition to Increase Bargaining Power Health Plan Bargaining Power Provider Consolidation Competition to Capture Patients and Restrict Choice Competition to Reduce Costs by Restricting Services All of this Dysfunctional Competition Increases Proliferates Lawsuits The Root Cause: Competingtion at the Wrong Level Why is Health Care Competition at the Wrong Level? The Wrong Conception of Health Care Itself: The Commodity Mindset The Wrong Objective The Wrong Geographic Market The Wrong Strategies The Wrong Industry Structure The Wrong Information The Wrong Patient Attitudes and Motivation The Wrong Incentives for Health Plans The Wrong Incentives for Providers The Wrong Response from Employers Went Along Chapter 3: How Reform Went Wrong 3-1 to 3-32 The Rise of Group Health Insurance Limiting Payments to Physicians and to Hospitals Managed Care The Medical Arms Race The Clinton Plan Patients' Rights Consumer Choice Quality and Pay for Performance A Single Payer System Medical/Health Savings Accounts Non-Reforms Reforming Competition: The Only Answer Chapter 4: Principles of Value-Based Competition 4-1 to 4-4023 Focus on Value, Not Just Costs Unrestricted Unrestricted Competition Based on Results Competition Centered on Disease or Medical Conditions Over the Full Cycle of Care Quality and Cost Will Often Improve Simultaneously Value Improvement is Amplified by Addressing the Full Cycle of Care Health Care Value is is Driven by Provider Experience, Excellence, and Uniqueness at the Medical Condition Level Competition That That is Is Regional or National Information to Support Value-Based Competition Must Be Widely Available Innovations that Increase Value and Control Costs are Must Be Strongly Rewarded The Payoff of Value-based Competition Chapter 5: Strategic Implications for Health Care Providers 5-1 to 5-49 The Strategy Vacuum in Health Care Delivery Strategies Based on Value and Uniqueness Moving to Value-Based Competition Redefine the Business Around Distinct Medical Conditions Choose the Range and Types of Services Provided, Both Within and Across Locations Matching Services and Locations. Separating Providers and Health Plans. Organize and Manage Around Medically Integrated Practice Areas Moving to Practice Areas. Create a Distinctive Strategy in Each Practice Area Design and Implement Processes and Facilities That Enable These Strategies Defining the Care Delivery Value Chain. The Process of Process Improvement. Collect Comprehensive Results and Process Information in Each Practice Area, Covering the Complete Care Cycle Collecting and Acting On Clinical Information. Assembling Comparative Information. Making Information Transparent. Accumulate Costs by Practice Area and Activity over the Care Cycle Build the Capability for Single Billing for Episodes and Cycles of Care, and Migrate to New Approaches to Pricing Marketing Based on Excellence, Uniqueness, and Results Grow Locally and Geographically in Areas of Strength, Using a Medically Integrated Care Delivery Approach Information Technology as an Enabler of Value-Based Competition What Would Industry Structure Look Like? Overcoming Barriers to Value-Based Competition External Barriers Health Plan Practices. Medicare Pricing. Regulation. Internal Barriers Attitudes and Mindsets. Governance. Management Capabilities. Medical Training. The Structure of Physician Practice. Addressing Traditional Medical Structures The Benefits of Moving Early The Strategy Vacuum in Health Care Delivery Strategies Based on Uniqueness and Value Moving to Value-Based Competition Redefine the Business aAround Sets of Medical Conditions Choose the Range and Types of Services Provided, Both Within and Across Locations Organize and Manage Around Medically Integrated Practice Areas Create a Distinctive Strategy in Each Practice Area Design and Implement Processes and Facilities That Enable These Strategies Collect Comprehensive Process and Outcome Information in Each Practice Area, Covering the Complete Care Cycle Accumulate Costs by Practice Area and Activity over the Care Cycle Build the Capability for Single Billing for Episodes or Cycles of Care, and Migrate to New Approaches to Pricing Market Based on Excellence, Uniqueness, and Results Grow Locally and Geographically in Areas of Strength, Using a Medically Integrated Care Delivery Approach Information Technology as an Enabler of Value-Based Competition What Would Industry Structure Look Like? Overcoming Barriers to Positive Sum Value-Based Competition External Barriers to Value Internal Barriers to Value Internal Barriers Addressing Traditional Medical Structures The Benefits of Moving Early Chapter 6: Strategic Implications for Health Plans 6-1 to 6-70 Past and Future Roles of Health Plans Enable Choice and Health Management Measure and Reward Providers Based on Results Maximize the Value of Care over the Full Care Cycle Simplify Reimbursement Systems Dramatically By Eliminating or Minimizing Administrative Transactions Compete on Subscriber Health Results Moving to Value-Based Competition: Imperatives for Heath Plans Improving Health Information and Patient Support for Diagnosis, Treatment, Disease Management and Prevention Organize around Medical conditions, Not Administrative Functions Develop and Assemble Information on Providers and Treatments Actively Support Patient Choice with Information and Unbiased Counseling Organize Patient Information and Interaction around the Full Cycle of Care Provide Comprehensive Disease management and Prevention Services to Subscribers, Even Healthy Ones Restructuring the Health Plan-Provider Relationship Shift the Nature of Information Sharing Reward Provider Excellence and Value-Enhancing Innovation for Patients Streamlining Contracting, Transactions, Billing and Pricing Move to Single Bills for Episodes and Cycles of Care, and Single Prices Simplify, Standardize, and Eliminate Paperwork and Transactions Move to Multi-Year Subscriber Contracts With Gain Sharing, and Shift the Process of Subscriber Plan Contracting End Cost Shifting Practices, Such as "Re-underwriting" Subscribers, that Erode Trust in Health Plans and Breed Cynicism Developing the Ability to Mange Subscriber Medical Records Provide the Service of Aggregating, Updating, and Providing Access to Patients' Complete Medical Record under Strict Standards of Privacy and Patient Control Overcoming Barriers to Health Plan Transformation Trust Information Health Plan Resources Provider Resistance Medicare Mindsets Culture and Values The Benefits of Moving Early Roles of Health Plans Implications for Health Plan Strategy and Operating Practices Health Information and Services Transactions, Pricing and Billing The Role of Industry Standardization Patient Medical Records Implications for Health Plan Resources Barriers to Health Plan Transformation The Benefits of Moving Early Chapter 7: Implications for Suppliers, Consumers, and Employers 7-1 to 7-39 Implications for Suppliers Moving to Value-Based Competition: New Approaches for Suppliers Offer Unique Value Over the Full Cycle of Care Demonstrate Value Based on Careful Study o Long-Term Results and Costs Ensure that Products are Used by the Right Patients Insure that Drugs/Devices are Embedded in the Right Care Delivery Processes Build Marketing Campaigns Based on Value, Information, and Customer Support Offer Services to System Participants that Add Value rather Than reinforce Cost Implications for Consumers as Subscribers and Patients Moving to Value-Based Competition: New Responsibilities for Consumers Participate Actively in Managing persona Health Expect Relevant Information and Seek help Make Provider Choices Based on Excellent Results, Not Convenience or Amenities Choose a Health Plan Based on Value Added Build a Long-Term Relationship with an Excellent Health Plan Act Responsibly Implications for Employers Missed Opportunities Promising Initiatives Moving to Value-Based Competition: New Roles for Employers Set New Expectations for Health Plans, including Self-insured Plans Provide for Health plan Continuity of Employees, Not Plan Churning Enhance Provider Competition Support Employees in Making Health Choices and in Managing Their Own Health Find Ways to Expand Insurance Coverage and Advocate Reform of the Insurance System Measure the Hold Staff Accountable for the Company's Health Value Received Chapter 8: Health Care Policy And Value-Based Competition: Implications for Government 8-1 to 8-64 Broad Issues in Health Care Policy Moving to Value-Based Competition: Health Insurance and Access Limit Unproductive Insurance Competition Eliminate Unproductive Billing Practices Clarify Legal Responsibility of Medical Bills Eliminate Balance Billing Encourage Higher Deductible Plans Together With Health Savings Accounts Enact Mandatory Health Coverage The Cost of Mandatory Coverage Moving to Mandatory Coverage Moving to Value-Based Competition: What Care Should Be Covered? Moving to Value-Based Competition: The Structure of Health Care Delivery Open Up Competition at the Right Level Antitrust Buying Group Practices Network Restrictions Conflicts of Interest in Referrals Regulation of New Entry State Level Licensing License Renewal Based on Performance Tax Treatment of Medical Travel Ensure the Collection and Dissemination of the Right Information Government and Information Collection Information Standards Mandatory Reporting Collection and Dissemination Infrastructure IT Standards to Enable Assembly of Records and Secure Information Sharing Private Sector Roles in Information Require Better Pricing Practices Transparent, Bundled Pricing Limits on Price Discrimination Reform Malpractice Redesign Medicare Polices and Practices Limitation of Medicare Pricing Practices Medicare Pay for Performance Towards new Pricing Models Align Medicaid with Medicare Moving to Value-Based Competition: Investing in Medical Research and Technology Continue Supporting Basic Scientific and Medical Research Create and Adoption of Innovation Fund Implications for Health Care Policy in Other Nations Conclusion: Redefining Health Care: Creating Value-Based Competition on Results C-1 to C-6 Bibliography About the Authors
Library of Congress Subject Headings for this publication:
Medical care -- Quality control.
Medical care -- Cost control.
Medical care -- Cost effectiveness.
Value analysis (Cost control).
Delivery of Health Care -- economics -- United States.
Economic Competition -- United States.
Quality of Health Care -- economics -- United States.
Health Care Costs -- United States.