Nearly 1,500 attendees gathered in Bethesda, MD, for AHRQ's Annual Conference September 9 to 11 to discuss the challenges facing health care and how health services researchers can turn those challenges into opportunities. In the first plenary session, "Carolyn Clancy 'Unplugged': A Conversation About the Research," AHRQ's director charted the course of health services research. "We need to find ways that we ourselves can do more to ensure that the fruits of our labor translate into innovation that makes the system better," she said. "We need to follow our research, follow up on it, to see that it reaches its point of intended use, whether that's at the point of care, to educate consumers and patients, or in the halls of legislatures across the Nation. The time for action is now."
The conference was held just 3 days after the Institute of Medicine released its report "Best Care at Lower Cost: The Path to Continuously Learning Health Care in America," which delivered all-too-familiar news for health service researchers on the state of the U.S. health care system:
- Unnecessary spending on health care totaled an estimated $750 billion in 2009.
- We have experienced an explosion in knowledge, innovation, and capacity to manage previously fatal conditions, yet we still fall short on fundamental issues such as quality, outcomes, cost, and equity.
- The Government and private sector need to accelerate payment reforms.
- Employers need to move beyond shifting costs to employees and begin demanding accountability from providers.
- Health care professionals need to engage more in collaboration with their peers.
The second plenary, "Implementation, Engagement, and Use: Making Health Care More Patient-Centered, Reliable, and Safe," enumerated the realities that the health care system is facing. Keynote speaker for the plenary, Reed Tuckson, M.D., FACP, executive vice president and chief of medical affairs, UnitedHealth Group, listed four longstanding challenges the field is facing. The first is cost. Commercial employers, small business owners, Medicare, and States do not have any extra money to pay for health care, noted Tuckson. "The only place to go to get any more money to pay for health care in America is the American people, the consumer, the average person," he said. "When our industry continues to escalate cost, do you know who the person is who is going to pay the bill? It is the average American. It is not some faceless gnome out there. These are real people."
The second challenge is that "the country is facing a tsunami of preventable chronic illnesses washing through a delivery system that we already can't afford," he said. "We are about to put a bolus of preventable chronic illness into a delivery system that is already unaffordable." Suboptimal quality and use of existing expensive assets is the third challenge. "$750 billion of waste—did you really need to be reminded that we're already p---- away our assets at unbelievable rates? Half of health care is using the best evidence-based medicine, half of the time," he said.
Finally, because individuals who have preventable chronic illnesses will be entering a highly technical delivery system, they will likely live a long time, which means they have to have their care coordinated. But the current care system is too fragmented in silos and disconnected across systems. "We are facing the collision of two dramatic diametrically opposed sets of forces," Tuckson said. "On the one hand, we have exciting new capacities, exciting new capabilities, which will enable us to make real exciting innovations in wellness, in health promotion, disease prevention, and in medical care delivery. On the other hand, we have extraordinarily severe affordability challenges, which have an unsustainable impact on health care cost and the cost to our society."
Engaging patients holds promise for answering some of these challenges. Because experts think that patients are part of the problem of inefficiency and waste in the system, they also believe that patients should be part of the solution and bear more responsibility for outcomes, said plenary panelist Kristin Carman, Ph.D., M.A., from the American Institutes for Research. "What do patients think? If patients are asked to take on increased accountability, then they want authority to go with that. Patients must be partners at the table, just as they are. Everybody's got to get out of their comfort zone," she said.
Engagement entails more than giving a patient a list of questions to ask, because for some people, it may be difficult for people to do that, said panelist Joe Betancourt, M.D., M.P.H., from Massachusetts General Hospital, who focuses on health equity and disparities. He related his own story of serving, as a 7 year old, as his grandmother's Spanish translator for a medical appointment. Despite his efforts and the fact that both the doctor and his grandmother smiled and nodded their heads, Betancourt heard his grandmother say after the appointment that she wasn't sure what the doctor had said and wasn't going to do it anyway. "She saw him as an authority figure and didn't feel comfortable questioning him," he said. "When we're thinking about engagement... we need to ask how can we work together to the best possible outcome and then build a team around what patients need."
Panelist Pamela Hyde, J.D., administrator of the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services, said the system has an obligation to structure practice to engage patients. For instance, her team engaged practitioners, clients, advocates, family members, and others to come up with an integrated suite of support tools, including the computer-based decision aid "What's Right for Me? Considering the Role of Antipsychotic Medications in My Recovery Plan." "We don't think of it as encouraging people not to take their medication," she said. "In fact, we think it actually helps people get the right medication and stay on it."
Ensuring patients receive high-quality health care regardless of their ethnicity also can help contain costs, Betancourt said. For example, because minorities suffer more medical errors and are more likely to be readmitted to the hospital with congestive heart failure within 30 days than their white counterparts, their care costs are higher.
"If we are progressive... we see the cost connections between all these issues and quality and safety. Our inattention to meeting the needs of those who are most vulnerable among us costs us a lot. We fail to account for all the ways these inefficiencies cost us every single day in both dollars and lives. The cost conversation, it is not rocket science."
Cost containment may also result from creating a health care system that coordinates care—including social services. For example, if a child who is insured by Medicaid has asthma, not only should the system be accountable for ensuring he has an inhaler and gets the right immunizations, it should also ensure that his home is free of allergens, such as rodent droppings, which can trigger asthma attacks.
"We don't think how to stitch together the medically necessary social support services as part of the continuum of health," Tuckson said. "That's that soft stuff over there, that social work." Value will inevitably force change. Corporations, business owners, States, Medicare, and the average consumer are asking the tough questions: What are we buying? What are the cost effectiveness and the quality of what we are buying? "Everybody cannot have everything all the time," Tuckson said. "Somewhere along the line, tough choices have to be made. You can't avoid it. You can't spend $4 trillion on health care. There is a limit."
"We need disruptive innovation in the tools that we have," he said. "We need new things that take quality higher and drive costs down. If it doesn't do that, then we don't need it."
Role of Research
To be relevant in the future, health services researchers need to do a better job of communicating how their piece of the puzzle fits into the bigger picture, Clancy said. "For people to see how what you're doing relates to the problems they have to solve, they have to know what you're doing a lot earlier in the process," she said.
Further, the field needs to more quickly determine what works and what can be scaled up and spread. "There's no shortage of will and excitement across the country, but there's a shortage of understanding of how to do this and what needs to happen," Clancy said. "It's a long process and the research community needs to be a part of this."
As an example of research that successfully scaled and spread, Clancy cited the AHRQ-funded Comprehensive Unit-based Safety Program that Johns Hopkins University developed to reduce central line bloodstream infections. The program was deployed in Michigan intensive care units and later in hospitals nationwide. In Michigan, some units reduced their rates to zero for more than 2 years, she said, and the national project's final report is due this fall.
"This is your moment. This is what you have been waiting for. This is why you trained. This is the reason you became health services researchers. Are you ready?" Tuckson asked.