**3. Medical practice should be organized around medical conditions and care cycle**

The organization we have today is by specialty, so a patient who has a condition that needs the effort of different specialties will bounce around from office to office to get his treatment. The reform should be made that patients only go to one place and have a team ready to address their different problems related to the initial condition in the same visit. Organizing around medical conditions and care cycle will be a major change for physicians but a great improvement for patients [3].

Effective care should be centered around a medical condition. That will need the effort of multiple physicians and other health professionals. This organization is known as integrated practice unit (IPU). The IPU is formed by physicians and nonphysicians who provide the full cycle of care for the patient. We will review them further along the text.

The scope of services should be accounted for concentrating volume in fewer locations, choosing the right location for each service line, and integrating care across locations.

Defining the scope of service is to reduce or eliminate service lines where value cannot be achieved. Another possibility is to create partnerships or affiliations with services that you have eliminated because of the lack of possibility of creating value for patients [15].

The concentration of volume in fewer locations is to create a consumer-oriented healthcare. Volume matters for value. The more you treat a disease and the more you learn, the better your treatment will be and more value will be created for the patient. This can be very difficult for organizations to achieve [15].

To choose the right location for each service line is of high value for patients. Less complex conditions should be moved away from high-value facilities to lowcost facilities. It's important to match complexity and the skills needed to the right location. That will optimize cost and productivity [15].

The integration of care across locations is the final component for health system integrations. This concentration of services around different locations must be tied together to improve patient's experience across the sites. All have been directed by IPUs and their physician managers [15].

Value for the patient comes from the effect of the entire set of activities and not only from a single specialty, and the value is greater when all of the four changes above are made.

The MD Anderson Cancer Center in Texas is one of the places where this set up was made. They are organizing around cancer type, and all relevant specialties needed are found in every one of those centers [1].

This approach changes the way physicians manage their practices and their patients. In primary care, for example, they will participate in a number of care cycle teams and they will focus, maybe, in disease diagnosis [3]. The complete cycle of care includes many areas and may take months or even years for the cycle to come to an end. Surgery is one part of care and physical therapy another.

It is thought that increasing value for the patient and the patient feeling well taken care of will reduce the number of malpractice suits. When you have more outcomes measured and a good data collection system, if you get sued you have better data that you can use to defend yourself.

#### **4. Results must be measured**

There cannot be an improvement in value for patients without measuring the results. The outcomes for every medical condition and the cost for achieving it need to be measured. Good measures are vital, and they enable professional insight and the development of expertise [16].

This is easier said than done because it may not be so straightforward to measure value or outcome. They can mean different things to different people, and unifying that is a challenge. Many medical associations all over the world are trying to do just that, some with relative success.

One thing we need to recognize is that health consists of physical, mental, and social health. All three must be in order to consider someone healthy and that need to be taken in consideration when measuring results for patients [17] and when a measurement tool is being done. To measure results by improvement on the initial condition alone is not good enough and should not be done.

The results should be measured by condition and care cycle, not specialty or even intervention. It should cover the full cycle of care until after care is completed and taken in consideration the social and mental status. According to Dr. Porter, the outcomes fall into three tiers. Tier 1 involves the health status achieved. Tier 2 outcome relates to the nature of the care cycle and recovery. Tier 3 outcomes relate to the sustainability of health [15]. If all tiers of outcome work well, costs will go down and productivity will go up.

If we want the value-based model to be successful, we need to measure outcomes. If we measure a minimum sufficient set of outcomes for every major medical condition and then standardize them nationally, we are one step closer to this model's success, but that has proven to be difficult.

First, quality is not defined as improvement in outcomes by today's standards. Second, the measurements that have been done are done by specialty societies but the aim is to treat the patient around a care cycle, not by a single specialty or a single procedure. Third, outcome measurements have focused on clinical status rather than functional outcome, which is the patient goal after all, to improve quality of life. And finally, every organization and even physician have their own set of

**181**

*Value-Based Healthcare*

to achieve [18].

*DOI: http://dx.doi.org/10.5772/intechopen.93378*

with excellent outcomes for the patients.

**5. Integrated practice units**

conditions of the patient.

measurements and outcomes, and that leads to inconsistencies in definitions and results. A regional, national, and global standardization is needed, but that is hard

fairly easy to spread round the country and around the world.

the data for future analysis, such as electronic medical records.

The International Consortium for Health Outcomes Measurement (ICHOM) has convened groups of experts on specific diseases to set a minimum standard set outcome and risk factors using a structured process [18]. Once this is done, it should be

One important thing for this to work is the implementation of information technology. The development of software that can automatically collect and aggregate

It is believed that in the near future, this is something that will be implemented all over the world with good results for everyone involved in healthcare, especially

An integrated practice unit (IPU) is a multispecialty team that collaborates to provide the best outcome to the patient at the lowest cost. These IPUs are encouraged to compete among themselves for the best possible outcome at the lowest cost during the cycle of care. The IPU will treat not only the disease but also all related

The team is responsible for the patient's full cycle of care. That encompasses outpatient, inpatient, rehabilitation, and supporting services such as nutrition, social work, and others. The team is also accountable for the outcomes and costs. Usually with IPUs, we have faster treatment, better outcomes, and lower costs.

Since the IPU focuses on disease, it is not clear how a patient with multiple diseases at the same time, and not necessarily correlated, will be conducted. Does he have to seek multiple IPUs to treat each of his diseases or only the one? Some say that the need to go to multiple IPUs may cause almost the same problem we have in today's system. The West German Headache Center can be considered an IPU. It includes neurologists, physical therapists, and psychologists who work together to treat every patient. The patient sees all experts they need in a single visit. If diagnostic imaging

Care delivered in an IPU should be structured. Just the fact that everybody is in the same place does not mean it works well and is integrated. The creation of

One important thing for an IPU is volume. Volume is needed to achieve better results and improve value to patients. The more you study and the more you treat a disease, the better you get at it. Experience is a key point for the deliverance of value. With that you can incorporate more parts of the cycle of care in your facility. The creation of an IPU can be challenging. A good example of how to make it work is as follows. The Navy launched in Jacksonville at their hospital a value-based program. They selected four of the most common condition to be the starting point [20]. A physician and a nurse were selected to lead each of the four IPUs that were created, and then they recruited other physicians, physical therapists, nurses, and others to be on the IPU. The teams received training on VBHC by external experts and the entire hospital too. Evidence-based treatment and outcomes were defined for later examination; the location, structure, and schedule were also defined by the team. The IPUs met weekly to monthly to discuss patients and treatments. When a treatment was not working, the team would come to an agreement to change it [20].

All that are achieved by the amount of patients they are able to see.

is needed, it is obtained from a nearby partner provider [19].

Three out of the four IPUs created were successful.

evidence-based guidelines will incrementally improve value to patients.

#### *Value-Based Healthcare DOI: http://dx.doi.org/10.5772/intechopen.93378*

measurements and outcomes, and that leads to inconsistencies in definitions and results. A regional, national, and global standardization is needed, but that is hard to achieve [18].

The International Consortium for Health Outcomes Measurement (ICHOM) has convened groups of experts on specific diseases to set a minimum standard set outcome and risk factors using a structured process [18]. Once this is done, it should be fairly easy to spread round the country and around the world.

One important thing for this to work is the implementation of information technology. The development of software that can automatically collect and aggregate the data for future analysis, such as electronic medical records.

It is believed that in the near future, this is something that will be implemented all over the world with good results for everyone involved in healthcare, especially with excellent outcomes for the patients.
