Institute of Medicine Report: Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Highlights for the Cancer Community

James Conway

On September 6, 2012, the Institute of Medicine (IOM) released the report Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.¹ The aim of this report, authored by the Committee on the Learning Health Care System in America, was to identify how the effectiveness and efficiency of the current healthcare system can be transformed, and to develop recommendations for actions that can be taken to achieve that end. This study builds on earlier IOM studies of various aspects of the healthcare system, from To Err Is Human: Building a Safer Health System,² on patient safety; to Crossing the Quality Chasm: A New Health System for the 21st Century,³ on healthcare quality; to Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,4 on healthcare disparities. The study process was also facilitated and informed by the 6 years of published summaries of workshops conducted under the auspices of the IOM Roundtable on Value & Science-Driven Health Care. Sponsors of the report included Blue Shield of California Foundation, Charina Endowment Fund, and the Robert Wood Johnson Foundation.

Overall Findings and Recommendations
Healthcare in America presents a fundamental paradox. The past 50 years have seen an explosion in biomedical knowledge, dramatic innovation in therapies and surgical procedures, and management of conditions that previously were fatal, with ever more exciting clinical capabilities on the horizon. Yet, the IOM report Best Care at Lower Cost finds that America’s healthcare system has become too complex and costly to continue business as usual.

Inefficiencies, an overwhelming amount of data, and other economic and quality barriers hinder progress in improving health and threaten the nation’s economic stability and global competitiveness. At the same time, the report notes there is significant evidence that the knowledge and tools exist now to put the health system on the right course to achieve continuous improvement and better quality care at lower cost.

In the area of costs, including both financial and harm, the system’s current inefficiency underscores the urgent need for a system-wide transformation. Healthcare costs have risen at an unsustainable rate – increasing at a greater rate than the economy as a whole for 31 of the past 40 years. Yet, the report found that a substantial amount of this investment was wasted. It calculated that about 30% of health spending in 2009 – roughly $750 billion – was wasted on unnecessary services, excessive administrative costs, fraud, and other problems. Part of the reason for this waste comes from the way that healthcare is paid for and reimbursed. Most payment systems emphasize volume over quality and value by reimbursing providers for individual procedures and tests rather than paying a flat rate or reimbursing based on patients’ outcomes, the report notes. Regardless of the cause, these inefficiencies cause needless suffering. By one estimate, roughly 75,000 deaths might have been averted in 2005 if every state had delivered care at the quality level of the best performing state.

The report says better use of data is a critical element of a continuously improving health system. About 75 million Americans have more than 1 chronic condition, requiring coordination among multiple specialists and therapies, which can increase the potential for miscommunication, misdiagnosis, potentially conflicting interventions, and dangerous drug interactions. Health professionals and patients frequently lack relevant and useful information at the point of care where decisions are made. And it can take years for new breakthroughs to gain widespread adoption; for example, it took 13 years for the use of beta-blockers to become standard practice after they were shown to improve survival rates for heart attack victims.

The committee found that engaging patients and their families in care decisions and management of their conditions leads to better outcomes and can reduce costs. Yet, such participation remains limited. Increased transparency about the costs and outcomes of care also boosts opportunities to learn and improve and should be a hallmark of institutions’ organizational cultures, the committee said. Linking providers’ performance to patient outcomes and measuring performance against internal and external benchmarks allow organizations to enhance their quality and become better stewards of limited resources, the report says.

In framing the plan for moving forward, the report finds that incremental upgrades and changes by individual hospitals or providers will not suffice. Achieving higher quality care at lower cost will require an across-the-board commitment to transform the US health system into a “learning” system that continuously improves by systematically capturing and broadly disseminating lessons from every care experience and new research discovery. It will necessitate embracing new technologies to collect and tap clinical data at the point of care, engaging patients and their families as partners, and establishing greater teamwork and transparency within healthcare organizations. Also, incentives and payment systems should emphasize the value and outcomes of care. The ways that healthcare providers currently train, practice, and learn new information cannot keep pace with the flood of research discoveries and technological advances. How healthcare organizations approach care delivery and how providers are paid for their services also often lead to inefficiencies and lower effectiveness and may hinder improvement.

The report outlines the characteristics of a continuously learning healthcare system – science and informatics, patient-clinician partnerships, incentives, and culture – and offers 10 foundational, care improvement, and supportive policy environment recommendations (Table).

Implications for the Cancer Community
Cancer is frequently cited in the report for its successes, such as the improvements cancer care has achieved in 5-year survival rates, for its experience in developing and using evidence-based practice guidelines, and for often generating evidence from routine cancer care. The cancer professional considering the recommendations will be struck with their resonance not only in successes but also challenges and gaps. No doubt they will also be energized with the possibilities and power of a learning healthcare system for cancer.

Familiar to cancer care are the struggles in the translation from science to evidence to care to improved patient and family experience. There are challenges in performing high-quality, coordinated care in the existing disaggregated environment. Cancer care is delivered by many, and often unconnected, players – in the home, office, local hospital, regional academic setting, and hospice by patient and family, healthcare providers, not-for-profit associations, and others. Furthermore, clinicians must confront the complexity of different treatment options and understand the variations of the patient populations in their treatment responses. To overcome these challenges, cancer providers are enhancing, and will need to accelerate, evidence-based practice; implement shared decision making in all aspects of clinical care and research; and improve access and optimize the flow of their patients.

Drawing from leading-edge practices in cancer, the authoring committee emphasizes the power and privilege of patient- and family-centered care. The committee makes special note of the increasing role that communities must play in care, with care designed across the continuum. At the moment, patients and families are shuffled from place to place. In the future, the system must be integrated, designed to manage care across the continuum and facilitate outcomes through access, care, flow, and the reduction of waste and inequity. Note is frequently made of the growing emphasis in cancer on health and prevention as well as healthcare. Stakeholder organizations in communities must come together in support of health and healthcare.

The role of the policy environment clearly resonates in cancer. In pondering the role of financial incentives, the need for, and current lack of, reimbursement for palliative care quickly come to mind. With the growing emphasis on waste and value, the question is increasingly being asked on how we can assure the right cancer care in the right place at the right time; nothing more, nothing less. Efforts such as the ABIM-led Choosing Wisely campaign are consistent with recommendations in the report and inform our journey to answer these questions in partnership with the patient and family. Cancer care providers are already seeing the growing focus on outcomes and calls for greater transparency, particularly around financial outcomes. While financial outcomes are essential, they must be considered in the context of transparency of all outcomes: clinical, financial, service, and experience (staff and patient). This will require an accelerated emphasis in the cancer community; in the absence of other outcomes, finance will trump. Finally, leadership driven by a culture of teamwork, collaboration, and adaptability must deepen not only in organizations but, even more crucially, across them. Cancer care providers must continue to seize the power of communities of learning – in research, care, prevention, operations – and become master collaborators and continuous improvers across all organizations in the cancer space.

Closing
Since its release, the IOM report Best Care at Lower Cost: The Path to Continuously Learning Health Care in America has garnered considerable attention. At one end people are struck at the potential power of the recommendations to transform, the clarity of the path forward, the strength of the evidence, and the centrality of patient, family, and community in partnership with their care team. They are sobered, if not stunned, by the extent of the missed opportunities, waste, and harm when presented in the aggregate. Most already know them in their own experience or that of someone they love. It is now time the cancer community rapidly accelerates efforts to take, inform, and improve the Path to Continuously Learning Health Care in America.

References

1. Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2012. www.iom.edu/bestcare.
2. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999.
3. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.
4. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2002.

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