innovation under uncertainty: maintaining progress
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Innovation Under Uncertainty: Maintaining ProgressDavid Blumenthal, MD, MPP
President, The Commonwealth Fund
U.S. Health Spending is Larger Than the GDP of Most Nations
2Notes: Data is an estimate for 2014; current US dollars (not adjusted for cost of living).
Sources: International Monetary Fund, Altarum Institute, National Health Expenditure Accounts.
The Affordable Care Act
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• Where possible, build in an experimental design.
o Phased implementation.
o Concurrent controls.
ACOs.
Disease management programs.
Conditional payment for new therapies.
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Designing Evaluations in Complex Programs
The Evaluation Challenge Persists
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The Evaluation Challenge Persists
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• Qualitative evaluations.
– Look for findings that affirm or undermine theories
of causative relationships.
• Collect sound before-and-after data, and link changes as
carefully as possible to timing of interventions.
Second-Best Approaches
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Source: Furman J, “The Economic Benefits of the Affordable Care Act,” Presented at Center for American Progress, April 2, 2015.
Percent, 12-month moving average
Medicare Hospital Readmissions
Physician and Hospital Adoption of EHRs
29%
83%
9%
76%
0%
20%
40%
60%
80%
100%
1 2 3 4 5 6 7 8 9
Series1 Series2
Notes: Hospital data of those with at least a basic EHR system (ONCHIT, 2015); physician data of practices with any EHR system (National Center for
Health Statistics, 2014).
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Are Positive Trends Sufficient to Press Ahead?
• Like clinical care, policy-making is both science and art.
• We rarely have the luxury of unassailable evidence of
efficacy or lack thereof when it comes to a critical decision.
• When is evidence good enough?
• Depends on context.
• Depends on intervention.
• Depends on the anticipated follow-on results and
evolution of initiative.
Ideal vs. Practical in Evidence-Based Policy-Making
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• Build in opportunities for continued learning and refinement.
o Stages of meaningful use.
o Keep asking: what have I learned, and how can I learn
more.
• Inherent asymmetry between discontinuing a successful
program and an unsuccessful program.
Some Basic Rules
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• Comparative data from external sources is very helpful for motivating
quality improvement.
o But not always helpful for QI itself.
• Quality and safety problems originate in local process issues, and
improvement requires collecting data specific to these processes.
o Identification of flawed processes.
o Interventions.
o Rapid cycle evaluation.
o Revisions of interventions.
A Word About DIY Data
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PDSA Cycle
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• Get started.
• Build your own data collection and improvement capacities.
Don’t Wait for Feds
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Contact Information
• David Blumenthal
• Social media:
– @DavidBlumenthal
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