One of the biggest challenges in health care is how to provide innovative, high technology specialty care while reining in costs at the same time. Particularly at a large academic medical center like ours, providing ever-improving care and treating the sickest of the sick often seems unavoidably expensive. But it needn’t always be. Since 2013, we have tapped our front lines – our 1,500 physicians and thousands more nurses, PA’s, pharmacists and other clinicians – for ways to improve care and reduce costs, using an innovation incubator model that adapts venture capital investment approaches to find and scale the best ideas. To date, these innovations have saved an estimated $4 million in annual medical expenses while decisively improving quality. Here’s how we did it.
The initiative, called BCRISP (Brigham Care Redesign Incubator and Startup Program), invites clinicians to submit short proposals that answer five questions about their ideas: 1)
problem are they are trying to solve? 2) What is their proposed solution? 3) What specific goals would they aim to achieve in a 9-month pilot? 4) What is the potential financial impact (how much money would it save and for whom, including a rough ROI calculation)? And 5) Who have they identified as potential internal sponsors and stakeholders?
Historically, clinicians have been good at at describing the clinical value of care redesign proposals, but cost has typically been an afterthought — if it’s considered at all. By requiring contributors to calculate the expected ROI of their proposals we encouraged a new cost-focused mindset while also identifying proposals that were most likely to be sustainable.
From these 109 applications, the board has selected a total 31 semifinalist projects in two cohorts. Each semifinalist team received seed funding of up to $5,000, as well as coaching on project design and assistance with data acquisition, to further develop their proposal and start early implementation work. The semi-finalists then each pitched their revised proposals to the advisory board in Shark-Tank style events that were open to the public. Ultimately, the advisors have given 16 proposals the green light — and up to $50,000 and continued coaching — to launch their pilots. The following four give a flavor of the pilots’ breadth and depth.
Improving the transition to long-term acute care rehab. Patients discharged from intensive care to a long-term acute care rehabilitation facility suffer from complex and serious illnesses; more than 40% are readmitted to the hospital within 30 days. This pilot project created a multidisciplinary, cross institutional team to improve care during the transition from hospital to acute care rehab. The team meets with patients and families prior to discharge, providing them with information and coaching about the transition and identifying medical and social issues that may complicate the move. After discharge, clinical teams at both institutions hold weekly videoconferences to review the patients’ status, and BWH providers teleconference directly with patients to provide continuity of care and prevent unnecessary return visits to the hospital. The 9-month pilot reduced 30-day readmissions by more than a third (to 25%) – such a dramatic impact that BWH has extended project funding and is expanding it to additional intensive care units.
Increasing vaginal births after Cesarean section. Concerned by the national trend of increasing elective C-sections, BWPO OB/GYN clinicians created a “pop-up window” in the C-section scheduling software that would prompt staff about the likelihood of a successful vaginal delivery for patients planning a repeat c-section. Over the course of the pilot, BWH’s VBAC (vaginal birth after c-section) rate increased from 14% to 22%. After the pilot concluded, the tool remained live and the VBAC rate continued to climb to 27%.
Addressing Emergency Department super users. A small number of “super users” accounts for a disproportionate percent of emergency department visits. During one 12-month period, 50 patients accounted for 1,083 ED visits at BWH, or nearly 2% of total ED volume. Such overuse is inefficient, expensive, and frustrating for both patients and providers. To address this problem, the BCRISP program funded a pilot in which community health workers connected with super-user patients outside the ED to address the medical and non-medical issues that led to their frequent visits. These health workers also engaged with BWH hospital-based and outpatient providers to develop care plans for managing super-user patients. Patients reported that these interventions helped to more effectively address their health concerns, and we observed 82 fewer ED visits and 190 fewer hospital admissions than would have been expected.
Improving lung cancer diagnosis and treatment. Patients with potentially cancerous lung lesions benefit from rapid diagnosis and treatment. But the literature shows that patients with certain demographic characteristics — racial and ethnic minorities, women, the elderly or disabled, the socioeconomically disadvantaged – are less likely to have surgery for lung cancer when it’s warranted. A team from thoracic surgery and medical oncology at BWH launched a pilot to improve the diagnosis and management of these vulnerable patients. The program engages a “clinical strategist,” a position that combines aspects of traditional community health worker, patient navigator, and treating-clinician roles to assure patients get the right tests; coordinate testing (for example, to schedule all tests for the same day); and serve as a patient resource and advocate. During the pilot, the clinical strategist approach reduced average time to diagnosis from 175 days to 15 days, and average time to treatment from 194 days to 31 days. By heading off an average of 4 physician visits and 3 diagnostic tests per patient, and providing treatment far earlier in the course of disease, the clinical strategist model generated an estimated $19,000 in savings per patient.
While these and the other pilot programs have performed well – sometimes dramatically so – there have been various challenges along the way that other institutions can learn from.
Like most provider organizations in the United States, reimbursement is a confusing combination of traditional fee-for-service and newer risk sharing models. With multiple commercial and public payers, each with slightly different payment models, calculating internal financial effect of any care redesign effort becomes dizzyingly complex. While we have been able to estimate how increased efficiency reduces total medical expense with fair confidence, determining what investments make sense in our hybrid payment environment has been more difficult.
The system of recognition and rewards within academic medicine has also presented unexpected challenges. Within our institution, financial and professional rewards are typically realized through publication of peer reviewed research or via increased volume of clinical activity. Implementing practical projects — activities that arguably generate equal if not more immediate value for patients and the institution — have enjoyed less prestige. While the BCRISP model encourages publication and dissemination of knowledge learned through the pilots, the primary purpose is to quickly identify new care paradigms that improve quality and reduce expense, and to rapidly transform care delivery across our institution.
We were pleased to find, however, that our ability to fund only a small number of pilots didn’t undermine broad engagement. One reason engagement has remained high is that we’ve worked hard to connect unselected proposals to other efforts around the institution — making introductions between individuals doing similar work, sponsoring some applicants in internal process improvement training courses, and trying to identify any additional opportunities that might provide support. When we surveyed BCRISP applicants after our first cohort, we were relieved to find that not a single applicant reported that having applied to the program led to any decrease in interest in pursuing work that would improve value for patients. In contrast, the vast majority, even among those who received no financial or project support, reported that the experience had made them more interested in future work of this type.
Overall, BCRISP has been a transformative program for our physicians and institution — catalyzing understanding and engagement around improving value for our patients, bringing numerous exciting and innovative ideas forward for discussion and evaluation, and rapidly testing, implementing, improving, and scaling those proposals that prove both clinical and financial value.