Identification of initiatives and rationale
Prevent Hospital-Acquired Infections (HAI) proposes implementing changes to hospital procedures to reduce the frequency of HAI. Reports by the New Jersey Department of Health (2019) indicate that HAIs contribute significantly to the morbidity and mortality rates in the state.
Value-based Payment’s (VBP) rationale is to encourage evidence-based accountability and tangible improvements in clinical outcomes. It challenges healthcare workers to put more effort into improving the value of their services. Counte et al. (2019) argue that this model is better than the conventional fee-for-service approach as it encourages quality and efficiency. It encourages healthcare providers to adopt best practices and a holistic team approach to care.
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Consequences and Trends
Preventing HAI translates to fewer deaths and shorter hospital stays since there are fewer complications. It also reduces the average healthcare costs . Currently, insurance companies refund patients for the extra expenses due to HAI, leaving the financial burden on the hospital. With this initiative, the trend is towards non-reimbursements, which in turn improves profit margins. Preventing HAIs enhances access to care, which in turn increases the demand and reduces the supply of Primary Care Providers (PCPs). The shortage in PCPs then results in an increase in the non-urgent case in the ER. This, in turn, increases healthcare costs above what it could potentially achieve if patients were able to see PCPs.
With a VBP, the trend is improved overall care. Caregivers put more effort into care coordination, self-care support, post-discharge care improvement, and medical home. The initiative encourages better patient-centered care and developments in the delivery of chronic and preventive care. Consequently, it leads to a desirable trend to reduce cases of severe Chronic Physical Illnesses. VBP also reduces the average income for specialists due to the decreasing costs of healthcare, which pushes them to increase the number of services to maintain their income. While this scenario has increased healthcare costs from the baseline, it has not reached the full potential because of this supply push.
Comparison of the Scenarios
VBP had a higher overall score (2.29) than Preventing HAIs (-5.6) in the simulation, as displayed in figure 1. It scored highly in three out of five metrics (health, care, and inequality) while the letter scored higher in cost and productivity. This difference occurred despite both having equal funding. However, there was a difference in cumulative spending, meaning that other initiatives can be added to improve the performance of VBP.
Figure1: Combined scores for VBP and Preventing HAIs initiatives
Preventing HAIs resulted in a positive change in average healthcare costs. It decreased the total amount spent on lab services, facility, dental, physician, home health, nursing care, and prescription drug by -0.4%. This change is consistent with the report by Jia et al. (2019) that preventing nosocomial infections reduces the overall cost of care. On the other hand, VBP had no significant change in this variable. The following graph demonstrates these changes.
Figure2: Effects of preventing HAIs and VBP on healthcare cost
In the simulation, VBP led to a positive impact on health. It reduced the average number of people with severe Chronic Physical Illnesses (CPIs) by 0.1% but did not affect the rate of death. On the other hand, while preventing HAIs did not affect CPIs, it reduced the rate of death significantly. Both initiatives did not have impacts on untreated mental illnesses, urgent episodes, high-risk behaviors, or the average quality of life.
Figure 3: Effects of preventing HAIs and VBP on severe chronic illnesses
Of the two initiatives, only VBP had a positive impact on cumulative care. It improved the adequacy of preventive and chronic care, as illustrated below. It also reduced the rate of readmission and the number of specialist visits by 1.5% and 0.5%, respectively. Preventing HAIs did not affect these metrics. Both programs increased the number of non-urgent visits in the Emergency Room (ER) by higher margins (0.8% and 0.9%) compared to visits to PCPs (0.6% and 0.1%).
Figure 4: Effects of preventing HAIs and VBP on care
Preventing HAIs resulted in the worst outcomes in inequality. It led to an increase in the deaths attributed to disadvantage (incomes below 200% of the federal poverty line) by (1.1%). VBP did not have any effect on this metric.
Figure 5: Effects of Preventing HAIs and VBP on inequality
With the prevention of HAIs, the cumulative value of productivity of employees improved by 0.1%. VBP reduced the value of lost productivity by 0.5% as employees incurred losses due to absenteeism. However, it did not have a significant impact on their total economic output.
Figure 6: Effects of Preventing HAIs and VBP on inequality
Complexity Principles and Application
The principle of stimulating change by providing enabling conditions can help improve the outcomes of both scenarios. As the simulation showed, preventing HAIs and VBP leads to a shortage in the supply of PCPs. This can be corrected by hiring more doctors and caregivers to serve both the insured and non-insured population. To achieve this, they should increase local PCP residency programs and guarantee first income for the first year. This strategy will accommodate the high demand, which will consequently decongest ERs. With enough supply to meet demand, the cost of healthcare in the scenarios will reduce further to further. Another scheme is avoiding overcrowding hospitals by implementing pre-visit consultation services. The number of unnecessary visits to the PCPs and ER can significantly reduce with qualified nurses providing advice to patients at home.
Self-organization and emergence principles can help improve the outcomes of the VBP scenario. With a mechanistic approach, leaders make all decisions without consulting the people or considering their views. This strategy often faces resistance as the one VBP faces from specialists, which reduces its efficiency. In this scenario, a triggered supply push prevents it from achieving its full potential in reducing healthcare costs. Leaders need to involve healthcare workers before implementing the value-based model of Payment and forcing them to abide by it. This discussion is essential, as it will help them decide on the best strategy that suits both parties.
During this time, both parties can agree on ways to shield the caregivers from a reduction in their income, which will eliminate their need to push supply unnecessarily. One strategy to upset any supply-push response is reinvesting healthcare costs in the hospitals. Leaders should agree to commit a proportion of these funds to share among specialists and PCPs on top of their value-based salaries. This strategy will ensure that the cost-reduction resulting from VBP does not affect their income negatively.
Recommendations
Leaders need to provide better coordination and improvement of hospital efficiency. According to Hughes & Landy (2011), New Jersey has a poorly integrated and uncoordinated healthcare system. It is, therefore, paramount for leaders to make adjustments to fix it to improve the quality of care for its population. The leaders need to set the direction, tone, and vision for this kind of change by promoting and enabling cooperation between all stakeholders to ensure holistic delivery of care. They also ought to encourage and facilitate coordination between private and public health and insurance providers for the overall sake of the people.
Reducing the cost of healthcare should be a priority. A survey by Hughes & Landy (2011) reported that healthcare utilization and cost in New Jersey are among the highest in the country. In Essex County, the rate of uninsurance is higher (12%) than that of the state (9%), meaning that a significant population does not afford primary care (County Health Rankings & Roadmaps, 2020). It is, therefore, paramount to lower the cost of healthcare by allocating more funds as well as increase insurance coverage. Leaders can achieve this, c reating family and student pathways to advantage through education, tax credits, subsidies, living wage policies, and housing vouchers.
The leaders need to enable healthy behavior among people. This strategy helps in significantly reducing the number and length of hospital inpatient stays, as demonstrated below, using the Rethink Health model. It also reduces the frequency of non-urgent cases in the ER, thus avoiding the shortage of PCPs resulting from improved access to care. This trend occurs because people have reduced the onset and risks of severe and mild chronic illnesses ( Baker et al., 2012). Therefore, leaders in New Jersey need to invest more in initiatives to reduce risky practices and regular health fairs with free screenings.
Conclusion
New Jersey has a poorly integrated and uncoordinated healthcare system. From this paper, preventing HAIs and VBP are not adequate to fix it. While they influence some health positively, they also cause undesirable adverse effects that upset the system. Leaders should employ t he principles of stimulating change by providing enabling conditions and self-organization and emergence to improve the outcomes of these initiatives.
References
Baker, A. D., Gilley, J., James, J., & Kimani, M. (2012). “High Five to Healthy Living”: a health intervention program for youth at an inner city community center. Journal of community health , 37 (1), 1-9.
Brown, B., & Crapo, J. (2014). The key to transitioning from fee-for-service to value-based reimbursement. Health Catalyst .
Counte, M. A., Howard, S. W., Chang, L., & Aaronson, W. (2019). Global advances in value-based Payment and their implications for global health management education, development, and practice. Frontiers in public health , 6 , 379.
Hughes, R., & Landy, L. (2011). The Future of Healthcare in new Jersey [PDF] (1st ed., p. 10). THE RIPPEL FOUNDATION.
Jia, H., Li, L., Li, W., Hou, T., Ma, H., Yang, Y., ... & Luo, X. (2019). Impact of healthcare-associated infections on length of stay: a study in 68 hospitals in China. BioMed research international , 2019 .
New Jersey Department of Health. (2019). Department of Health | Health Care Quality Assessment | Healthcare-Associated Infections. Retrieved 13 April 2020, from https://www.nj.gov/health/healthcarequality/health-care-professionals/healthcare-associated-infections/
The County Health Rankings & Roadmaps. (2020). County Health Rankings & Roadmaps. Retrieved 14 April 2020, from https://www.countyhealthrankings.org/app/new-jersey/2020/rankings/essex/county/outcomes/overall/snapshot
