Advancing Health Care Quality and Controlling Costs: A Q&A with Ashish Jha

Combating rising costs and improving quality are two major concerns among stakeholders in the US health care system.

To address these concerns, the US government, insurers, and health care providers are placing increased importance on the implementation of new models of care and focusing on advancing alternative payment methods and population health management, which are intended to incentivize health care cost effectiveness and quality, as compared to more traditional fee-for-service models. Further, advancements in information technology are providing a growing universe of data that health care analysts can tap into to understand how these initiatives are impacting access to higher-quality, lower-cost care. 

To explore this topic, Managing Principal Stephen Fink spoke with Analysis Group affiliate Ashish K. Jha, who served as the White House COVID-19 Response Coordinator during the Biden Administration. Following the conclusion of his appointment, Professor Jha – a physician with years of experience practicing both in the private sector and in the Veterans Health Administration – returned to his position as dean of the Brown University School of Public Health. In litigation, he has provided expert testimony to both regulators and parties involved in challenges to health care mergers and acquisitions.

In this conversation, Professor Jha addressed a theme that stretches across the breadth of his academic and professional experience: how policy recommendations and business decisions could be improved through a better understanding of different approaches to assessing drivers of health care quality and costs.

As both a practitioner and policy expert, what are some of the biggest changes that you have seen across the health care landscape in the US over the last 20 years?

At the beginning of the 2000s, health care in the US was delivered and paid for almost exclusively under a fee-for-service model. That is, individual payments were required for every office visit, procedure, medication prescribed, and test ordered. As you can imagine, the use of this model led to high health care costs and often resulted in poorly coordinated and lower-quality patient care. 

In a move away from fragmented fee-for-service models, policymakers in the US are increasingly focused on incorporating alternative payment models, which could help providers and systems deliver more clinically integrated, population-based health care. In contrast with fee-for-service models, alternative payment models can create an environment in which providers bear some financial risk for the care that they provide, theoretically incentivizing them to both reduce wasteful care and deliver better care. These efforts have often been tied to an observable shift toward population-based models, which can incentivize a high degree of clinical integration among providers. This is because population-based patient care is focused on the health of everyone in a particular population (be that defined by geography or by employment with a major employer), rather than exclusively on individuals who might walk through the door of a physician’s office or an emergency room. This more proactive approach to health care requires incorporation of other drivers of health – including social factors (often described as social determinants of health), lifestyles, effective chronic disease management, and nonclinical interventions such as ensuring adequate housing and nutrition – in assessments of health care quality. Medicare – the single largest payer for health care services in the US – intends to shift all patients to such a population-focused alternative payment model by 2030.¹

 

How could this transition affect assessments of the cost effectiveness or quality of health care?

As the nation moves toward a philosophy of population-based health management, understanding whether health systems are meeting their goals of providing high-quality care while being smart financial stewards will likely require a grasp of different approaches to assessing data about those goals. During the COVID-19 public health emergency, we saw that data-driven, population-focused initiatives could help health systems deliver critical care efficiently. In the post-pandemic era, it will be incumbent upon researchers, policymakers, and health care providers to continue to leverage the data available to them to improve recommendations around health care quality and costs, especially in the context of population-based initiatives.

In my research, I have applied a framework that was initially developed by the National Academy of Medicine to analyze health care quality and outcomes. At its core, this framework was built to examine care inside the walls of a hospital. But as more and more care has shifted to the outpatient setting and we are increasingly concerned about the health of people who rarely touch the health care system, the notion of caring about an entire population (not just the patients who show up to their appointments) must be considered as part of a more holistic approach to assessing the drivers of quality and costs.

Could you say more about those considerations? What drives health care quality and outcomes?

When I think about high-performing health systems and what they do differently and better, I think of four major drivers: providers, IT infrastructure, systems, and incentives. The fact that providers – including clinicians, doctors, nurses, and others – affect health care quality and patient outcomes should come as no surprise. But there are two important considerations here that don’t often get enough attention. First, you have to have the right mix and the right number of providers. There is no single right mix but there are plenty of wrong ones. The second part of such an assessment is how well those providers work together: When providers collaborate effectively, treat patients holistically, share the same information, and pull in the same direction, they can be said to be clinically integrated. Such integration can lead to better continuity of care – that is, more seamless and less fragmented care – for patients, which can boost health care quality and improve outcomes. Relatedly, if the IT infrastructure of a hospital or health care network supports such clinical integration, then the quality of care available to patients, the outcomes that they experience, or the costs that they incur may also be positively impacted.

When we talk about systems, we are really talking about two things: the processes that a hospital has in place, and the leadership and culture present at that hospital that allows for those processes to be followed or otherwise reorganized if they are ineffective. Finally, we have to pay attention to incentives. You can have a great set of providers, great processes, great leadership, and great tools (such as IT), but if the incentive system under which you work doesn’t reward quality and efficiency, it’ll be hard to sustain high-quality, efficient care. For example, a hospital may be incentivized to rethink the ways that it provides care to patients due to its transition away from a traditional fee-for-service payment model and toward a population-based model. Ultimately, it is important to understand that each of these four drivers is a piece of an interconnected puzzle: Events that affect one driver can affect the others, which could produce a knock-on effect on a health system’s ability to deliver high-quality care.

How might this method for analyzing health care quality be relevant to the assessment of merger considerations?

I think that – prior to any hospital merger – a thorough analysis of data on the merging parties’ individual track records on safety, quality, and outcomes is necessary. In such an assessment, it is important to take a holistic approach and analyze multiple data sources to see if consistent themes emerge from those data. Will a merged entity deliver higher-quality health care to patients through improved clinical integration, access to technologies, systems, or a new set of incentives? A fact-specific inquiry is necessary to answer that question. That is because context matters: Health care quality and outcomes can improve as a result of some mergers and decline in other scenarios. Understanding how a merger could affect the drivers of health care quality and efficiency can help stakeholders assess whether that merger would affect quality itself.

Merging parties would also do well to understand – as early as possible in the process – the specific improvement plans that are in place or are being developed by each organization involved in a merger to ensure that the merger indeed leads to meaningfully better, higher-quality care. This is because a thorough analysis of the drivers of health care quality and outcomes can take time. After identifying areas for improvement based on an assessment of the drivers of health care quality, developing detailed and actionable plans is essential, something that I have found often can benefit from getting an outside perspective. Too often, merging parties overlook the quality issue – or pay vague lip service to it – until late in the process. And while that’s understandable (there are lots of moving parts in a merger), it is unfortunate and can often derail mergers or leave the post-merger organization worse off. Prioritizing specific and detailed quality improvement plans is critical in the context of organizations coming together. This kind of initiative is a topic I’ve explored in detail with hospital leadership in many contexts.

 

Given your experience with planning for impending hospital mergers, how could health care leaders and providers best prepare themselves to deliver high-quality care following a merger?

The same aspects of a holistic assessment of health care quality that we have discussed can be identified and turned into a specific set of assessments, both before and following a merger. Specific, actionable plans are important tools that organizations can develop to help increase the likelihood that merged entities will achieve high-quality care post-transaction. These plans will inevitably vary. For example, some hospitals may need to rethink the infrastructure that supports clinical integration in a combined entity following a merger. Others may need to focus on a new structure for their provider network that will ensure coverage during a transition period. Post-transaction plans will be specific to each hospital system and must be tailored accordingly.

As I mentioned earlier, a fact-specific inquiry is critical to accurately assess how merging parties can provide high-quality and low-cost care after they come together. ■

 

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Sources

1. Driving Health System Transformation - A Strategy for the CMS Innovation Center’s Second Decade, Centers for Medicare and Medicaid Services, October 2021