The Basics of Value-based Healthcare Delivery — the Care Process Design System

The Commonwealth Fund in 2019 showed that the U.S. spends more on health care as a share of the economy — nearly twice as much as the average OECD (Organization for Economic Cooperation and Development) country — yet has the lowest life expectancy and highest suicide rates among the 11 nations in the OECD (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States).

So, the most basic fact that needs to be understood about VBCD is that it needs to improve or maintain quality while lowering costs and here is what needs to happen:

1. Individual providers and their care teams need to design processes and procedures that they perform on a regular basis. This may be something as common as the care of patients with a chronic disease (e.g. diabetes, heart failure, or hypertension) to procedural processes of care (e.g. joint replacement, bypass surgery, endoscopy, etc ).
2. These care processes and procedures should be designed, using best practices as outlined in the scientific literature while also considering and not discounting the knowledge and experience of those on the care team. These local providers are best positioned to know what will work with their specific patient population, facilities, equipment and skill levels.
3. After the care processes and procedures are designed, a simple map should be developed that includes each major step used in the process or procedure. These maps don’t need to be sophisticated. Each step however, should also include the staff, equipment, supplies, and space required to carry it out effectively.
4. Next, straightforward quality and cost outcomes should be defined for each process or procedure. Attempts should be made to ensure quality measures represent true outcomes (e.g. average hemoglobin A1C levels for diabetic patients) and that true costs of care delivery are measured using activity based cost (ABC) accounting for each process or procedure. Software is now available to facilitate the capture of such measures but individual / local providers can also use their own medical record and accounting systems to come up with acceptable quality and cost outcome measures.
5. Finally, the above quality and cost measures should be reviewed periodically (weekly, monthly, quarterly) the the care team and the underlying processes and procedures should be modified if this data shows outcome measures are trending in the wrong direction. Further modifications in care delivery may also be implemented over time as new information becomes available about what works best for specific conditions.

The beauty of the above system known as the Care Process Design System (CPDS) is that it can be implemented at the frontlines by individual providers and thus constitutes the engine which can drive bottom-up rather than top-down value improvement efforts.

The most common complaint I hear from providers when discussing standardization of evidence-based care across the healthcare system, as a whole, or within components of the system, such as hospitals or healthcare systems, is “that won’t work in my practice”. The CPDS has the power to overcome this type of pushback and resentment by many of having to practice what some call “cookbook medicine”.

In my opinion, no legislation, payment guidelines, or regulatory standards will work as well as the CPDS to unleash the innovative power of those who care for patients on a regular basis. Physicians and others who are in such positions of responsibility should be encouraged and given the authority (and accountability) to design and spread a truly high-value care delivery system that will finally provide high value for those we serve, i.e. the patient.