Best Care at Lower Cost: The Path to Continuously Learning Health Care in America

American health care has two overarching imperatives: To manage its ever-increasing complexity, and curb ever-escalating costs.If banking were like health care, ATM transactions would take days or longer as a result of unavailable or misplaced records. If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with little coordination. If shopping were like health care, product prices would not be posted, and the price charged would vary widely within the same store - depending on the source of payment. If auto manufacturing were like health care, warranties would not exist, few factories would monitor and improve production line performance and product quality. And if airline travel were like health care, each pilot would be free to design his own preflight safety check, or not to perform one at all.One contributor to increasing complexity is the rapid increase in biomedical and clinical knowledge - research publications have gone from over 200,000/year in 1970 to over 750,000 in 2010. Another - the prevalence of chronic conditions has increased - from 125 million in 2000 to a projected 157 million in 2020 as the population gets older. More than 20% of those over 65 receive treatment for multiple chronic diseases. Managing these multiple conditions requires a holistic approach, creating uncertainty for clinicians attempting to manage the treatments. With specialization, clinicians must coordinate with multiple other providers - Medicare patients now see an average of seven physicians, including five specialists, split among four different practices. One study found that in a single year, a typical primary care physician coordinated with an average of 229 other physicians in 117 different practices just for Medicare patients - blurring accountability. Still another - rising administrative burdens and inefficient workflows - hospital nurses spend only about 30% of their time in direct patient care.If all states provide care of the quality delivered by the highest-performing state, an estimated 75,000 fewer deaths would have occurred across the nation in 2005. The current system for capturing and using new knowledge is flawed and likely to be overwhelmed by the increasing pace of knowledge growth. Use of checklists eliminated catheter-related bloodstream infections in the ICUs in most hospitals in one study, and an 80% decrease in infections/catheter-day. Diffusion of new evidence can take eg. 13 years for thrombolytic drugs between when they were shown to be effective and when most experts recommended the treatment.There is also evidence that a substantial proportion of health care expenditures is wasted. IOM estimates $210 billion for unnecessary services, $130 billion for inefficiently delivered services (eg. unnecessary use of higher-cost providers, errors), $190 billion for excess administrative costs (eg. insurance paperwork costs beyond benchmarks), $105 billion for prices that are too high, $55 billion on missed prevention opportunities, and $75 billion on fraud.Clinicians reimbursed for each service tend to recommend more visits and services - most payment methods pay without focus on patient health and value. One study wound, on average, only a 4.3% correlation between quality of care delivered and price - with higher prices often associated with lower quality.Strong leadership focused on continuous improvement is essential.