WASHINGTON -- They call it " Investigators mine insurance claims data, rank clinicians on total per capita spending, and on the best available measures of quality. Then, they find where those two metrics intersect.
In other words, the bright spots.
Oddly, most clinical teams don't even know when they're providing high value care, noted Arnold Milstein, MD, director of Stanford University's Clinical Excellence Research Center (CER), who spoke at a on Friday.
"They had no idea that they were so substantially outperforming their peers," he said.
But the Center's researchers see this value.
And they dig into the claims to see what makes these high performers different, Milstein added.
Dementia
One of the challenges driving healthcare costs is "friendly fire."
That's how Nick Bott, PsyD, also at Stanford's CER, characterized situations where the medical services you deliver, while seemingly necessary and well-intended, can actually speed patients' decline.
Patients with dementia or cognitive impairment are more likely to be hospitalized than those without these conditions, but for this population, these acute hospitalizations can be dangerous, he said.
"If you actually think about the particular environment that a hospital is, which is bright lights, no windows, bells ringing, tons of people that you don't know -- it's a completely disorienting experience even for a relatively healthy adult," Bott told 鶹ý.
"And so you put an older adult who might have some cognitive impairment on board in that situation and it doesn't take much to realize how it can be a very disoriented and frankly a traumatic kind of event."
One in three people with cognitive impairment or dementia will end up with "hospital-acquired delirium" following a hospitalization, and post-mortem studies show that delirium in the presence of dementia accelerates the rate of cognitive and functional decline, Bott explained.
Fortunately, there are solutions -- for example, the (HELP), a multi-component, non-pharmacologic prevention and management of delirium protocol.
The HELP protocol involves basic measures such as adequate hydration, early mobilization, cognitive stimulation, reorientation to time and place, and assessing the adequacy of hearing and vision issues.
When feasible, another protocol, the "acute care at home" or Hospital at Home protocol, which allows patients to obtain hospital-level care in their home or apartment, can also be leveraged.
In addition to avoiding "transfer trauma," keeping patients in their homes, is often a more convenient way for family members to visit and support loved ones, and patients have an easier time becoming active again after the medical intervention is completed, he explained.
"In a hospital, it can sometimes be so easy to take on the patient identity that it actually incapacitates you more than you otherwise would be," Bott said.
This contributes to the risk of delirium and de-conditioning, he added.
For clinicians, the model is beneficial because it's easier to see a patient's day-to-day problems, such as mobility challenges, from inside their homes.
A third component in the delirium-management protocols is "prehability before elective surgeries," in which a clinical team helps assess patients and manage the risk of delirium.
A geriatrician assesses the risk of confusion after surgery to help determine the goals for that surgery; the occupational therapist assesses the patient's home situation to anticipate post-surgery needs; and a physical therapist creates a physical conditioning program tailored to the individual patient, Bott said.
Total costs of care for dementia in the U.S. is about $230 billion annually and a quarter of the per-person annual payments go to acute hospitalization, he noted.
Implementing the delirium reduction protocols, such as HELP, alone could result in a 0.5% reduction in healthcare spending or roughly $12 billion in savings.
When you add in the Hospital at Home and prehabilitation protocols, savings amount to $25.5 billion or about 1% of total healthcare costs, Bott explained.
Maternity Care
Shifting maternity care to less costly settings can also drive down healthcare costs while preserving quality, Victoria Woo, MD, of Kaiser Permanente in Oakland, Calif., and a fellow at Stanford's CER, explained. "We know that costs for birth are increasing each year, but our outcomes are not better."
One alternative is to move more births to outpatient affiliated birth centers, where low-risk mothers can deliver their babies with the support of midwives, Woo explained.
While most birth centers are currently independently owned by a single midwife, if birth centers were to become hospital affiliated, they could mitigate any potential delays in care, if an emergency arose, she added.
There are several obstacles to implementing this kind of transformation.
One of the primary obstacles is trust.
Another challenge is that birthing centers are currently not required to be accredited and licensure differs in each state, and even in each county.
Among midwives at these centers, there is also a range of skill levels from nurse midwives to "lay midwives," who often acquire their experience by serving as an apprentice to another midwife.
Because there are no minimum standards, there is also heterogeneity in outcomes, Woo noted. "However, we know that birth centers used in an integrated system can have excellent outcomes."
Woo pointed to examples of free-standing midwifery units in the United Kingdom, which she said are akin to outpatient hospital-affiliated birthing centers in the U.S.
Low-risk women are able to deliver in these free-standing units and can be seamlessly transferred in the event they become high-risk.
Choosing a birth center could save about half the cost of birth, labor, and delivery in a hospital, and they have a lower rate of Cesarean sections and less medical interventions, Woo noted.
In the U.S. roughly 70% of births are low-risk. Even if 40% of these women delivered in a birth center, "you're looking at significant savings," she said.
Again, this single intervention, if scaled up across the country, would reduce healthcare spending by nearly 0.5%, Milstein said.