Wednesday, December 29, 2010

Value (Outcomes/Cost) –A Unifying Concept for Health Reform?

In health care, stakeholders have myriad, often conflicting goals, access to services, profitability, high quality, cost containment, safety, convenience, patient-centeredness, and satisfaction.

Michael Porter PhD, Professor, Harvard Business School, “What is Value in Health Care, “New England Journal of Medicine, December 23, 2010

Those who support the new health reform law and those who seek to repeal it look at the new law through vastly different ideological lenses. Each ideological camp has its own implacable, rarely movable spin on what’s important.

But, according to Thomas Lee, MD, associate editor of the New England Journal of Medicine and networks president for Partners Healthcare System in Boston, the search for value (outcomes relative to cost) unites and provides a path forward for competing ideological interests.

In Lee's words, “The value framework offers a unifying framework for provider organizations that might otherwise be paralyzed by constituents’ fighting for bigger pieces of a shrinking pie (“Putting the Value Framework to Work," New England Journal of Medicine, and December 23, 2010).

As an ideological and idealistic concept, I would like to think a utopian vision focusing on value is achievable. But I remain dubious because of the nature of American culture. I am also skeptical partly because the concept originates in Boston, which has the highest health costs in the nation but which has scanty evidence that its outcomes are superior. Finally, I am leery because it takes large organizations with interoperable and expensive electronic systems that communicate with each other to measure value (outcomes/costs) for a bewildering number of different diseases with different outcome dimensions (survival, degrees of health recovery, time to return to work, side effects, pain, complications, adverse effects, sustainability, long term consequences) all measured over a longitudinal time frame among diverse stakeholders. Bringing such scattered data points into a single focus with a common understanding among diverse participants over a long time frame strikes me as nearly impossible.

It takes a large integrated organization, or a virtual organization with standardized measuring systems to do this, and I simply do not see this happening soon in America. In Doctor Lee’s words, it means “capturing data in different parts of the delivery system, which means that we all have to use the exact same terminology. And it means sharing accountability for performance.”

To paraphrase Hillary Clinton, “It will take a extremely large village,” or a unified homogeneous nation, and I do not see that happening soon in a country as diverse as America.

My wife, my son, and I have just returned from New Hampshire. The state's motto is “Live free or die,” perhaps the best known of state slogans. The slogan reflects an assertive independence grounded in the American political philosophy of small government, individualism, freedom of choice, freedom of behavior, all which bear on outcomes and costs.

In New Hampshire we stayed at a bread and breakfast inn that served a communal breakfast. At our table was a Brazilian physician, a general practitioner, who now works as a faculty member in a university philosophy department. She espoused the philosophy of a universal health system shared by all nations based on the concept of health care as a “right” for every citizen of the world regulated by the World Health Organization. In other words, she believes in a worldwide health care utopia.

As a pragmatist and a student of American culture, I thought her concept was unworkable for the world in general and American in particular. So we fell into a discussion on the obstacles of sweeping health reform in continental, multicultural, individualist nations like the U.S. or Brazil, each with vast differences between the rich and the poor.

We disagreed agreeably, and I referred her to the work of Porter and Lee in Boston, emanating out of the Harvard medical academic complex. She liked what she heard. We agreed to have further discussions via email on seeking common ground for all patients.

For me the problem is not philosophical but practical. How does one control costs while meeting American's and their lawyer's expectations. No matter how stringent government regulations are, Americans have high expectations. We want more rather than less care. We are easily satisfied with the best.

Besides. with regard to cost, the poorest in America are the sickest and most expensive. Poor people are and will not able to afford or may not have sufficient information or funds to seek preventive or routine care. They will show up on the doctor’s or hospital’s doorstep with advanced disease, and costs to treat them will be high, as they are now in southern states like Mississippi and in America's inner cities. The government now pays for them with Medicaid or Medicare funds but sooner or later Americans will tire of paying higher taxes, and doctors will tire of government regulations and low Medicare and Medicaid reimbursements. and may not be there to care for them.

I close with three 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.


Anonymous said...

Being able to measure value is only the first step. The system must also be able to predict value in outcomes, only then can an assessment of cost-benefit be made.

When making widgets, there is a high degree of certainty in most process and manufacturing decisions, and a relatively high predictability of customer satisfaction (with appropriate marketing analysis, etc.).

But variability and uncertainty is very high in medicine. Even in a common, easily measured problem like high blood pressure, we don't know when or if it will lead to more symptoms, and we have little ability to predict in any specific patient which medicine will work the best to improve the measured pressure (let alone improve overall outcome).

Knowing where you want to end up isn't a panacea if you don't know where you are and what the path is like.

Anonymous said...

Thank you for your insightful comments. There is another factor as well - blood pressure and test variability. I once had blood drawn on myself daily over a two week period under varying conditions. Tests like glucose, uric acid, serum iron, and cholesterol varied by as much as 40% from day to day, and rom morning to afternoon

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Thanks so much for this article, quite effective piece of writing.

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