Comments on Yesterday’s Value (Outcomes/Cost) Blog

Preface: Yesterday I posted a blog on the value of measuring outcomes of various diseases based on cost. The Health Care Blog, probably the most widely read of blogs pertaining to health care policies, reran my piece. In my blog,I expressed skepticism about the practicality of value measurements based on outcome measurements on a broad scale across the medical care spectrum. I closed with these questions. Here are the comments from readers of The Health Care Blog.

I ended my blog with these questions.

1. Is overall health care value measurable?

2. Are the organizational, societal, and individual costs required to make this value measurement worth it?

3. Will the measurement of value unify ideological factions competing to advance the cause of health reform?

I have my doubts.

Comments

YES, YES AND YES.
I AM SKEPTICAL OF YOUR SKEPTICISM. My colleagues and I created WWW.HospitalValueIndex.com as a means to test this hypothesis, and the response from the industry was remarkable. It didn't cost the government, taxpayers or you anything, and it didn't require HITECH or ARRA or Meaningful Use funding. Not a single academic was distracted from research and not a single patient's care was rationed.

What VALUE does is help all constituents re-frame their thinking around the complex issues that you describe, without giving up on the ultimate goal. Thousands of management teams have learned from this perspective, and it was FREE.
Advancing this concept to the breadth you describe is attainable and it will soon shape how we think about measurement. BTW, Porter/Teisberg went on to say so much more than your selected skeptical quote, and inspired me to find meaning in Value that much sooner. I think it is the kind of innovation we all deserve.

TRG
Posted by: John R. Morrow | Dec 30, 2010 7:57:18 AM
In response:

1. Potentially yes. Currently we lack 'outcomes' standards for measurement of the value numerator. Mere reporting of compliance and broad based definitions are too variable and do not necessarily address the relevant consumer i.e. the patient. There must be a clear definition of the appropriate outcomes which may not always be 'survival' 'infection rate' etc.

2. YES. The cultural advancement that is required to empower the patient to realize their role in determining the structure of value-based care will be difficult. Additional positive externalities though might relate to improved overall health, prevention and responsibility. Perhaps unreachable, but worth the investment.

3. Doubtful. To follow on Porter/Teisberg, the ultimate focus should be at the disease and patient level. This may directly contradict some of the goals of our insurers, hospitals and pharma/device companies...at least initially.

Posted by: Stephen J. Motew, MD, FACS | Dec 30, 2010 1:29:42 PM

yes, yes, and see below.

I think one can argue endlessly over what metrics to measure, how to measure them, whether measuring them is feasible, etc. etc. etc. and, in fact, these arguments have already been going on in health care for many years. It is tatamount to the arguments in my childhood between the US and Soviets (I believe they were the other party) over the size and shape of the negotiating table before they would sit down to negotiate - which held up progress for quite some time.

The bottom line is that all parties have to come together at some point and agree on what to measure and how to measure it - and this will inevitably be somewhat arbitrary. The point is that the same yardstick will be used for all, and that we will progressively evolve these measurements as we go. Right now every insurance company, hospital, doctors' group, and any other group in health care is measuring its own things in its own way, resulting in the present chaos.

See this post from Paul Levy's blog as a rather stunning example of one hospital's required "quality" measurements, without even the value calculation (note he says it is only a partial list):

http://runningahospital.blogspot.com/2010/09/pay-for-performance-and-motivation.html
Posted by: bev M.D. | Dec 30, 2010 2:35:18 PM

1. How is value defined? Whose values? Physicians and HC researchers may agree on, say QALY or other outcome parameters (or surrogate parameters). Patients may care more about access (both financial access as well as local care with good parking), ill-defined and ill- understood "innovation", physician rapport, comfort incl. luxurious birthing suites ... the sick do care about outcomes, but they may be skewed towards hope (for example, take the advocacy for useless ALS drugs, or the research on MS of disease of impaired venous reflux).

The only way to make real (outcome based) value count and to preserve choice would be a value based plan in competition to a conventional 3rd party pays all plan, with financial interest of the insured in cost.

3. Seriously? That ideological factions (incl. death panel republicans) stop using HC reform for political ends?
Posted by: rbar | Dec 30, 2010 3:58:06 PM

My Response to Comments

I find these comments instructive and helpful.

First of all, I am pleased to learn John Morrow and his team have been able to implement Porter’s value concept. Perhaps I overestimated the difficulties.

Secondly, I note De. Motew, a surgeon, is considerable more guarded but nevertheless open-minded. Maybe there is a complex solution for every complex problem

Thirdly, I found Paul Levy’s comment realistic, “The bottom line is that all parties have to come together at some point and agree on what to measure and how to measure it - and this will inevitably be somewhat arbitrary. The point is that the same yardstick will be used for all” and that we will progressively evolve these measurements as we go. Right now every insurance company, hospital, doctors' group, and any other group in health care is measuring its own things in its own way, resulting in the present chaos.” Anything that brings order out of chaos is welc.oem

Fourthly, I found the last comment about ideological factions and their use of HC reform to advance their political cause a bit off-putting. He mentions “death panel republicans’ but fails to cite the “historic achievement democrats.” We all have ideological axes to grind, and we will continue to grind them.