“How are you going to get the innovation out? How are you going to get the acceptance from your fellow colleagues around the country that this provides savings in some sort of way? Doing the right thing isn’t enough. It has to work in their business model.” – Steve Shields, Action Pact Development, LLC
Health care service and delivery innovations occur within the context of budget restraints and scarce human and fiscal resources. Making the argument that the innovation is “the right thing to do” is not sufficient. As noted by many panel members, innovations are stronger candidates for scaling if they can rigorously and demonstrably prove their cost effectiveness in ways that satisfy key supporters of spread efforts. As Lisa Suennen explained, “The return on investment is all that matters to payers….They’re not going to spend money for programs they’re going to lose money on.” It is also important for providers.
However, some innovations may save money and even produce other desirable outcomes such as higher quality of care, but Fishbowl Panel experts and innovators agreed that the current parameters of the health care system may mean that they will still be challenging to spread. For example, Linda Wick can substantiate the cost effectiveness and higher quality of her intervention on CHF. However, broader SUS efforts would have to clear two major hurdles: 1) possible objections from payers to purchasing disease management services for only one condition; and 2) current diagnostic practices that make conventional disease management services look more effective than they are, undermining the market for alternatives. As Ms. Wick explained, CHF is over diagnosed, creating the misleading impression that conventional disease management services are adequately treating it when, in fact, their apparent success in avoiding rehospitalization lies in the fact that many of their “CHF patients” do not actually have the disease.
Another cost factor central to the business case is reimbursement. In the case of David Dorr’s innovation, health plan expert Adam Zavadil observed that primary care practices are often funded by six or more different payers, making it difficult for an individual payer to justify funding the full cost of an innovation. He recommended a community engagement approach to payment in which multiple payers would jointly decide to fund different components of the innovation. In this example, the shared financial burden could increase the appeal and value to payers, but this model will likely not translate to all settings or clinical scenarios. Regardless of the mechanism, reimbursement remains a crucial factor in determining the feasibility of adoption and should be addressed in the business case for the innovation.
The business case for an innovation must also consider the issue of competition and market differentiation: why potential adopters should adopt one innovation over other innovations or current practices. The innovation must be well positioned within the context of their adopting organization by, for example, bundling it with related services. For example, Joseph Skelton’s innovation focused on reducing obesity among children might be bundled with related service lines such as bariatric surgery services. Hospital executive Janell Moerer stated that integrating the innovation’s benefits into the institution’s other goals and values could make it more attractive to health care executives. She recommended that Joseph Skelton investigate options for framing his innovation in altruistic terms attractive to her hospital and others, and align it with the system’s mission of creating closer linkages with local communities.
Lastly, the business case should take into account the innovation’s ability to be sustained over time. Tom Graf from Geisinger Health System described a formal tool that his organization developed to gauge the likelihood of continued support for an innovation. This four-pronged tool uses indicators of 1) professional satisfaction and professional impact, 2) patient impact, 3) financial impact, and 4) quality. Dr. Graf stated that good performance in three out of these four areas typically indicates a sustainable innovation.