IDENTIFYING KEY AREAS FOR DELIVERY SYSTEM RESEARCH The Challenge and Promise of Delivery System Research: A Meeting of AHRQ Grantees, Experts and Stakeholders Lawrence Casalino M.D., Ph.D. Weill Cornell Medical College Sterling, VA February 16, 2011

This talk - a quick overview: what is delivery system research? conceptual model criteria for selecting key areas for delivery system research four key areas and research questions ARRA grantees 2

Why study the delivery system? patients, legislators, the media, physicians mostly don’t see a problem But: the discoveries of basic scientific and clinical research do not help patients unless they are effectively used in the delivery system. 3

What is delivery system research? focuses on organizations that provide health care and/or inter-relationships among these organizations 4

Generic model of an organization and its incentives 5

Criteria for selecting key areas for delivery system research (1) will this research help patients—either directly or by helping providers to provide better care? (Clancy) does this research have potential for a major impact on the population as a whole or on subgroups? (IOM) 6

Criteria for selecting key areas for delivery system research (2) focuses on areas emphasized by the health reform law studies both intended and unintended consequences 7

Criteria for selecting key areas for delivery system research (3) Objective: to get providers into high performing organizations and give these organizations incentives to continually improve care for their population of patients - therefore: –identify types of organizations that tend to be high performing –identify incentives likely to lead to creation of these organizations and to movement of providers into them –identify incentives for organizations to improve care 8

Major gap in research and funding: focus mainly on processes of care, particularly intraorganizational processes this is important, but difficult to generalize, because: –process effectiveness depends on the way it is implemented and on the context within which it is implemented –most attempts to improve care involve multiple processes; how do we know which are important? also, organizations unlikely to adopt a process unless they have adequate incentives to do so 9

Qualifications/limitations just my opinions - no compelling evidence somewhat arbitrary choices - even with agreement on criteria, many choices are possible see the “long list” and the rest of the “short list” see the reasons given for selecting these areas better to be provocative and wrong than to be too general key areas likely to change over time 10

Key research area #1 analyses of the demographics of the delivery system—i.e., of each component of the conceptual model and of relationships among the components of the model 11

Why? knowing the demographics is an essential first step, which would make it possible to study in a generalizable way the inter-relationships outlined in the conceptual model between structure, incentives, processes, and outcomes huge gaps in knowledge very little funding available for this 12

Examples of research questions which type of medical group performs better: –small, medium, large? –single specialty or multispecialty? –hospital or MD-owned? is the percentage of physicians employed by hospitals increasing? If so: –why? –is this a good thing? 13

Key research area #2 analyses of ways to structure incentives so that they lead to: –desirable changes in the demography of organizations in the delivery system –continual efforts by these organizations to improve the health of their populations of patients 14

Why? incentives likely to be critical despite funding, we are far from having definitive answers 15

Examples of research questions compare the effects of different payment methods on quality, costs, and the demography of the delivery system how can undesirable unintended consequences of external incentive programs be minimized? 16

Key research area #3 how can performance measurement be improved? 17

Why? hard to improve what you can’t measure we often measure less, rather than more, important things increased reliance on external incentives (e.g. P4P, public reporting, “shared savings”)  measures had better be good 18

Examples of research questions at what level is it desirable and feasible to measure quality (e.g. individual MD, medical group, accountable care organization)? how much weight should be given to patient experience in evaluating quality? how can electronic medical records be used to measure performance? 19

Critical research area #4: Analyses of interprovider/interorganizational processes for improving care 20

Why? may be a major source of poor quality/poor patient experience/high costs little is known about this area 21

Examples of research questions can small practices effectively share resources (e.g. nurse care managers)? how valuable is phone communication among physicians about patients (even when patient is not referred)? If valuable, how can it be encouraged? 22

AHRQ ARRA CER Grantees lack time to do this any sort of justice 4/6 evaluation grants and 4/4 demonstration grants can be categorized as falling into the key areas suggested here 23