Do Health Care Delivery System Reforms Improve Value? The Jury Is Still Out.
BACKGROUND
Widespread restructuring of health delivery systems is underway in the United States to reduce costs and improve the quality of health care.


OBJECTIVE
To describe studies evaluating the impact of system-level interventions (incentives and delivery structures) on the value of US health care, defined as the balance between quality and cost.


METHODS
We identified articles in PubMed (2003 to July 2014) using keywords identified through an iterative process, with reference and author tracking. We searched tables of contents of relevant journals from August 2014 through 11 August 2015 to update our sample.


METHODS
We included prospective or retrospective studies of system-level changes, with a control, reporting both quality and either cost or utilization of resources.


METHODS
Data about study design, study quality, and outcomes was extracted by one reviewer and checked by a second.


RESULTS
Thirty reports of 28 interventions were included. Interventions included patient-centered medical home implementations (n=12), pay-for-performance programs (n=10), and mixed interventions (n=6); no other intervention types were identified. Most reports (n=19) described both cost and utilization outcomes. Quality, cost, and utilization outcomes varied widely; many improvements were small and process outcomes predominated. Improved value (improved quality with stable or lower cost/utilization or stable quality with lower cost/utilization) was seen in 23 reports; 1 showed decreased value, and 6 showed unchanged, unclear, or mixed results.Study limitations included variability among specific endpoints reported, inconsistent methodologies, and lack of full adjustment in some observational trials. Lack of standardized MeSH terms was also a challenge in the search.


CONCLUSIONS
On balance, the literature suggests that health system reforms can improve value. However, this finding is tempered by the varying outcomes evaluated across studies with little documented improvement in outcome quality measures. Standardized measures of value would facilitate assessment of the impact of interventions across studies and better estimates of the broad impact of system change.
*Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY†Department of Medicine, University of California San Francisco‡San Francisco VA Medical Center§Division of General Internal Medicine, University of California San Francisco, San Francisco, CA.
Deborah
D
Korenstein
Kevin
K
Duan
Manuel J
MJ
Diaz
Rosa
R
Ahn
Salomeh
S
Keyhani
D019317:Evidence-Based Medicine / Q000458:organization & administration; D018166:Health Care Reform / Q000458:organization & administration*; D006279:Health Maintenance Organizations / Q000458:organization & administration; D006284:Health Plan Implementation / Q000458:organization & administration*; D006801:Humans; D018802:Patient-Centered Care / Q000458:organization & administration*; D011320:Primary Health Care / Q000458:organization & administration; D058996:Quality Improvement / Q000458:organization & administration*; D014481:United States