Essentials of the U.S. Health Care System, Fifth Edition

Leiyu Shi and Douglas Singh

Case Study

Chapter 12: Cost, Access, and Quality

The overall effectiveness of a health system can be measured in a number of different ways. Health outcomes are an obvious measure and one that is tied directly to access to quality clinical care. The tracking of health outcomes involves tracking the progress of patients who present a chronic condition, such as hypertension, and then measuring the results after drug therapy and lifestyle changes. Additionally, patient satisfaction is a reasonable measure of the effectiveness of a health system. Measures of health outcomes, patient satisfaction, and cost reduction, when coupled together, are significant performance indicators for monitoring the overall effectiveness of a health system. The catalyst of U.S. healthcare reform and modernization is identifying, monitoring, and measuring the key performance indicators of cost, access, and quality.

Introduction

Measuring the cost of healthcare delivery is critical to evaluating the overall effectiveness of health systems. As noted by Porter and Lee (2013), “Improving value requires either improving one or more outcomes without raising costs or lowering costs without compromising outcomes or both” (p. 52). For example, the Patient Protection and Affordable Care Act (ACA) of 2010 sought to transform the U.S. healthcare system by creating synergies, efficiencies, and economies of scale that would reduce the cost of care delivery by spreading it across population health and disease management programs (Lathrop & Hodnicki, 2014).

Accountable care organizations (ACOs) are now part of value-based health services delivery and have grown in popularity since their inception over a decade ago. Despite the official-sounding description, an ACO is not a legal entity; rather ACOs are voluntarily established by healthcare providers, health plans, and hospitals to increase consumers’ access to health services and to reduce the collective costs of doing business.

Case Report

During the summer of 2018, Blue Cross and Blue Shield, the Texas-based health insurance behemoth, entered an ACO relationship with Baylor Scott & White Health, the largest nonprofit health system in Texas. Under the agreement, in year one Baylor Scott & White would provide high-quality care to upwards of 140,000 Blue Cross and Blue Shield members, establishing it as the most substantial value-based care agreement with a commercial insurance company in the United States (Rege, 2018). Improvements in health outcomes for those with chronic diseases such as diabetes, hypertension, and obesity can build patients’ confidence in the ACO model resulting from increased quality of life, leading to higher levels of customer satisfaction in the health system.

Discussion

The shift from healthcare delivery based on patient demand to a more proactive approach will require a complete commitment from all healthcare stakeholders. Due to its ACO alignment, Baylor Scott & White Health had over 1 million lives under value-based care arrangements, and stakeholders believe that their patients will receive high-value, coordinated, and quality care (Rege, 2018). Designing, implementing, coordinating, and managing the delivery of health services can increase care and oversight across the entire continuum of patient care (Wexler et al., 2014). These tighter controls at the point of service will lower costs across the entire system. Increasing emphasis on disease prevention will directly affect the rate of chronic conditions and traditional high-cost illnesses. Moreover, financial risk pools will create economies of scale as younger and healthier patients begin to purchase insurance plan resulting from the ACA mandates. Health policies and reforms such as the ACA demonstrate the government's meaningful efforts to reduce costs and increase access to and quality of care. These types of national standards are enforceable by government agencies with far-reaching authority. The lower cost of medical procedures coupled with reduced reimbursement rates from Medicare and Medicaid will fundamentally alter health care delivery in the United States.

Questions

1. Discuss the interrelationship between cost, access, and quality in the delivery of health services. Briefly describe the impact of each measure on positive patient health outcomes.

2. Under the ACA, describe a scenario of how medical providers and healthcare professionals work together to enhance the quality of health initiatives, interventions, or outcomes.

3. In your opinion, what role will ACOs play in the future environment of value-based health services delivery? Explain your answer by integrating an example of how an ACO can either reduce costs, increase patient satisfaction, or improve health outcomes.

References

Atkins, D., Kupersmith, J., & Eisen, S. (2010). The Veterans Affairs experience: Comparative effectiveness research in a large health system. Health Affairs, 29, 1906–1912.

Lathrop, B., & Hodnicki, D. R. (2014). The Affordable Care Act: Primary care and the doctor of nursing practice nurse. Online Journal of Issues in Nursing, 19(2), 7.

Porter, M., & Lee. T. (2013). The strategy that will fix health care. Harvard Business Review, 91(10), 50–70.

Rege, A. (2018, July 24). Baylor Scott & White's ACO strikes major value-based deal with BCBS of Texas. Becker’s Hospital Review. Retrieved from

Wexler, R., Hefner, J., Welker, M., & McAlearney, A. (2014). Health care reform: Possibilities and opportunities for primary care. Journal of Family Practice, 63(6), 298–304.