Throughout the history of the Health Disparities Collaboratives, the major barrier reported by health center leaders has been the lack of a business case to support the work of Planned Care. The reality is that a front-end investment of time, staff and fiscal resources is required to implement the Planned Care Model. Unfortunately, the colloquial experience of most health centers is that this investment of resources is not offset by new revenues or cost reductions. Although there is a compelling case for the impact of the planned care model on decreasing health care utilization and costs, those savings generally accrue to the payers and hospitals rather than to the primary care providers. As a result, the senior leaders have kept repeating the mantra of how do we pay for this work in order to sustain it?
In response to this question, in 2003 HRSA initiated a pilot collaborative to study aspects of both finance and office practice redesign within a group of nine community health centers. The pilot ended its first year of work with significant progress in the area of redesign, drawing upon change concepts that had been previously field-tested by the IHI and others. At the end of this year, however, much work remained to be done in the finance area, and the pilot was continued for an additional 9 months with five health center teams participating. The work of this second phase focused on the continued development of a change package and measures in the financial area, targeting three aspects of the business case: cost reduction through waste elimination; improved productivity; increased revenue through better billing and collection.
Through the work of the Finance and Redesign pilot, it has become clear that health centers can generate their own business case, even without dramatic changes in the reimbursement system. However, it requires recognition that the work of Planned Care is intricately tied to the financial performance of the organization. One of the traps organizations fall into is seeing the Planned Care work simply as a clinical quality improvement project. When viewed in this light Planned Care does simply add to the existing work of the care team that is assigned to the project. Rarely does the team of those assigned to work on Planned Care include colleagues who work in the administrative and financial areas of the organization. As a result, silos are perpetuated and the full talents of the organization are not harnessed to actually redesign the systems and processes in order to deliver higher quality care at lower costs.
Those who have been successful in driving their business case have adopted the notion of “quality as business strategy.” They have recognized that implanting the Planned Care model in their organization requires a total transformation of the organization. This work becomes an opportunity to understand the intersection of administrative, financial, and clinical systems and to use this knowledge to redesign all of these processes toward a leaner and higher performing organization. They realize that the traditional model of primary care delivery all of us have grown up with is perfectly designed to achieve the suboptimal results it is achieving. Implementing Planned Care is not about simply tweaking our old systems to get them to perform better. Rather, it is about designing new organizations that produce better outcomes with fewer resources. Once armed with this knowledge, health centers have demonstrated they are capable of making this transition.
To assist health center leaders with the transformation of their organizations and development of their business case, the faculty of the Finance and Redesign Pilot has developed a Leaders' Guide to Developing the Business Case for Planned Care. The Leaders' Guide PDF document includes a framework and guidance that health center leaders and staff can use in their efforts to drive their business case. Also included in the Leaders' Guide are a series of Toolkits that include the high leverage change concepts that have evolved from the work of the pilot. These Toolkits in turn include resources and specific tools that can also be accessed through links to the HDC website Library.
Click here to access the Leaders' Guide to Developing the Business Case for Planned Care. Again, links to the Toolkit resources are included within the Leaders' Guide document, or click on the Change Concepts links in the below list to go directly to the Toolkit resources posted in the Library.
High Leverage Change Concepts
Through the course of the Finance and Redesign Pilot, it became clear that the business case of a health center is affected by activity and changes implemented in all six components of the Care Model. The greatest impact, however, is found in the Organization of HealthCare and Delivery System Design components of the Model and those change concepts identified through the Pilot as high leverage opportunities are listed below. Those that represent primary economic drivers are marked with asterisks (*).
ORGANIZATION OF HEALTH CARE
DELIVERY SYSTEM DESIGN
To access the Toolkits that correspond to the change concepts listed above just click on the change concept in the above list. The same links are listed within the Leaders' Guide document in the Toolkits section. Each of the above change concepts links to a folder within the Library that contains the Toolkit resources to view and/or download. Also available in the Library is the Change Concepts Grid that includes these change concepts, change ideas, and examples of changes that can be made within a health center.
Measures
The first change concept of the Finance and Redesign change package involves the use of data to understand the practice of a health center and its business case. Once appropriate data is collected, it can be compared to industry benchmarks and specific health center goals, a gap analysis can be conducted, and plan for improvement to close that gap can be developed and implemented. To complete an organizational transformation and solidify the business case, various dimensions of the practice should be measured and monitored. These dimensions include clinical processes and outcomes, financial health of the practice, operational performance, staff vitality, and patient centeredness. Other dimensions may include those cited in the Crossing the Quality Chasm report: Effectiveness, Efficiency, Timeliness, Safety, Patient Centeredness, and Equity. The Finance and Redesign Pilot identified 10 measures that reflect multiple dimensions of health center performance.
These measures include:
- Time to third next available appointment
- Office visit cycle time and value-added time as a percent of total cycle time
- Panel size per FTE provider
- Operating expenses per encounter
- Revenue per encounter
- Encounters per FTE provider
- Percent self-pay collections
- No show rate
- Percent of patients who would recommend the center
- Voluntary staff turnover
In addition to these measures, traditional clinical outcomes measures as defined by HDC topic area are also included as balancing measures to those of finance and redesign.
Although the use of data and measures such as those above is essential to system level improvement, health center staff is cautioned that efforts to track these measures may be accompanied by many challenges. The health centers participating in the Finance and Redesign Pilot were confronted by lack of data availability due to inadequate information systems or lack of internal transparency, cumbersome data collection processes, inherent time lags on some financial data, as well as definitional inconsistencies across multiple health centers. Understanding and anticipating these challenges up front places health centers in a better position to overcome them.
Click here to access the Finance and Redesign Measures document that includes operational definitions and target values.
Additional Information and Resources
The Leaders' Guide and Toolkits are intended to be user friendly resources to assist health centers with driving their own business case. A Bibliography has also been prepared to provide additional resources on the business case for planned care.
Key Contact Information:
Fred Butler, HRSA
Phone: (301) 594-4483
Christine St. Andre
Phone: (480) 513-2560
Date Created: April 25 , 2006
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