1st Annual Crossing the Quality Chasm Summit: A Focus on Communities http://books.nap.edu/catalog/11085.html
from rapid-cycle practical models and, in parallel, using these experiences to inform and develop a firmer scientific base.
It was suggested that if self-management is to be recognized as an integral component of high- quality care, demand for these services must be created among clinicians and patients and incorporated into the mainstream health care culture. Barriers to widespread adoption of self- management practices include brief, rigidly scheduled office visits, which are not conducive to more labor-intensive interactions, such as completing a patient-generated action plan, and the lack of reimbursement for self-management support. Additionally, self-management programs must be flexible enough to allow for tailoring to individual patient preferences, as well as culturally, linguistically, age, gender, and lifestyle appropriate. Particular attention should be paid to health literacy and the ability to assimilate and process medical information (IOM, 2004). As with care coordination, defining roles and making more efficient use of the talents and skills of all members of the health care team are necessary, along with teaching these principles in academic and clinical settings. Families and other caregivers also need to be supported and provided adequate resources to assist patients in managing their condition.
Box ES-7. Finance: Key Strategies
Instituting performance-based payment models
Implementing evidence-based benefit design
Providing payment for proven quality support services—care coordination and patient self- management support
Engaging consumers with information and incentives
As a core strategy, participants proposed shifting to performance-based payment models that pay for performance and align incentives with evidence-based high-quality care. This approach assumes that the problem may not be one of insufficient resources, but of substantial waste and variation in the current health care system (Fisher et al., 2003a,b). Thus any changes to the present finance system would be budget neutral—redirecting and redistributing revenue streams in the many organizations that make up the larger health care system, rather than adding to the total funding for that system.
Infusing evidence-based medicine into benefit design was identified as another way to apply resources toward more effective care. For example, benefit packages could be created that would cover bundles of high-value services known to work clinically for chronic illnesses— such as HbA1c monitoring, annual eye and foot exams, lipid testing, and blood pressure control for diabetics.
The strategy of empowering consumers to modify their behavior by using monetary incentives or providing them with information important to their health was also proposed. As with all of the proposals in this area, the aim is not to simply shift costs to consumers—as is the growing trend—but instead to institute cost sharing with consumers, designed with the specific intent of encouraging them to obtain the right care at the right time. Finally, as discussed by participants addressing care coordination and self-management, reimbursement for these support services will require a shift from the current piecemeal approach of paying for individual clinician encounters to paying for elements linked to systems of care involving a team of diverse practitioners.
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