"New Rules" to Guide Health Care Redesign

The Affordable Care Act has created unprecedented opportunities to transform the health care system—most notably by creating programs that reward providers for delivering better care at lower cost. As a result, health care leaders are now in a good position to tackle longstanding problems that have hampered the work of frontline care providers.

To understand how this transformation is playing out, our Commonwealth Fund research team has been observing the Leadership Alliance, an initiative of the Institute for Healthcare Improvement (IHI), which brings together leaders from 40 health systems to learn from one another and chart a new course.

One of the Alliance’s first steps was to propose “new rules” to redesign the health care system (see box). Much like the IHI’s “Triple Aim”—to improve care experiences, improve population health, and reduce per capita costs—the rules are designed to be aspirational rather than prescriptive. And while they are framed broadly, the rules can be applied to guide improvements for vulnerable patients, including those with low incomes, and those with complex needs who incur high costs; these groups may have the most to gain and are of particular interest to The Commonwealth Fund.

The new rules also point to the dysfunction that underlies many of the unwritten rules governing health care today. Today, for instance, patients must move from one setting to another and one specialist to another in search of diagnoses and care. Those who fail to make the moves—because of lack of transportation, inadequate insurance, or other barriers that disproportionately affect the vulnerable—often fail to get care. Thus, one of the new rules—move knowledge, not people—would deliver relevant information to patients and their providers, whenever and wherever they need it.

Members of the Leadership Alliance are working to put the new rules into practice—hoping to demonstrate to their colleagues as well as policymakers that rapid and radical change is possible. Here we reflect on how some of the rules might improve care for vulnerable and high-need populations, among others.

Under the “old rules,” patients with complex needs often encounter a “one-size-fits-all” health system that fails to take account of individual goals for care. A new rule, customize to the individual, would shift this paradigm so that services are designed to meet the needs and preferences of patients, rather than the convenience of payers or providers. Likewise, change the balance of power would encourage patients and their families to take a leading role in their own care and to share in making decisions consistent with their values.

Two of the new rules, standardize what makes sense and make it easy, would remove the redundancy that many patients with complex conditions encounter when asked to repeat tests and medical histories. Streamlined work processes and use of technological tools also would make it easier for care teams to reliably choreograph the many tasks that must be done well to effectively manage patients with complex needs.

For providers serving vulnerable populations, rules such as eliminate walls can make good business sense. This rule encourages partnerships between health care institutions, schools, social service agencies, and other organizations to help address social and economic issues that can impede good health. By assuming abundance in this way, stakeholders would cooperate to make the most of existing resources and assets.

Following the rule return the money would mean savings would be shared with patients, employers, and communities to ensure care is affordable and to promote health or invest in other sectors such as education or housing that influence the determinants of health. Not only would such efforts help those who struggle to pay medical bills, they could benefit all of those who live in poor and underserved neighborhoods.

Continue the Conversation

We’d like to hear what you think about these new rules: are they likely to promote a higher-performing health system—especially for vulnerable populations and patients with complex care needs who account for a disproportionate share of spending?

To share your thoughts on the new rules, join us in a tweet chat on June 3rd at 2 p.m. EDT as the IHI’s Don Berwick, M.D., Elliott Fisher, M.D., of the Dartmouth Institute for Health Policy and Clinical Practice, and Jenn Verma of the Canadian Foundation for Healthcare Improvement, lead a conversation about redesigning health care in the U.S. and abroad. Join us at #IHIAlliance.