Monday, 21 April 2014

Better health per dollar spent

"Better health for dollar spent", Michael Porter’s celebrated phrase, summarizes, like no other quote, the spirit of the current focus of clinical management. Porter is a professor at the Harvard Business School renowned worldwide for his work on company strategy and competitiveness. This professor shocked the world of health services when in 2006 he published ”Redefining Health Care", a book in which the author put his finger on the pulse of the American health care system, when he said he did not understand the organization in specialties that had little to do with the needs of patients. Neither did he understand how there were no indicators to measure the value that the ”health industry” contributed to the people’s health, nor how the clinical activities are remunerated per volume of work done, regardless of achieved health outcomes.

In an article in JAMA in 2007, Porter said that competitiveness in values ​​is the basis of the economy and that in the health system only the doctors can achieve it, if they set themselves the goal that clinical activities have a final purpose and not a meaning in themselves. 

For this reason, in this work, the teacher encourages doctors to become aware that they need to rethink what they do, based on the following three pillars:

  1. The main objective of the clinical activity is improving people’s health.
  2. Clinical practice should be reorganized according to the patients’ diagnoses and disease’s own cycles.
  3. The results, adjusted per risk and per cost, should be measured.

Reading it this way, surely you thought of these as three obvious advices. Everybody would endorse them. But if you look carefully, despite the obvious minimalism, each statement hides the keys to a deep rethinking of everything we do and how we do it.

To illustrate (not summarize), this new way of seeing things, I chose six porterian pearls from the aforementioned article:


The real situation for now, is that we have a model that once organized in hierarchies moved the hierarchy from the university cathedrals to the hospitals organizations. And one must admit that this updated the new “insurance hospitals” as opposed to the current model at the time that was outdated and ill equipped to face emerging modern medicine.

Then came the structuring of the system (’in the eighties) with the onset of primary care reform (at least in Spain) and the subsequent reform of specialized care. And this was also good. It brought order and proximity.

Despite these historic successes, now, with the population’ aging and with the appearance of chronicity of geriatric frailty, the model is gripped between levels of care tightly structured, specialized and departmentalized clinical services according to the organs’ logic and to the anatomic systems. It's funny that someone from outside the health system, a teacher of ”business” expertise on competitiveness and an American liberal, shows us the way with so much clarity.

"Get rid of the shackles of the past," he says. Look for teams of professionals dedicated and organized around specific health problems, teams that adjust their agendas to the cycles of the diseases they serve, that are capable to integrate more and more services needed to improve the health of their patients, that gain experience in what they do and that are remunerated according to the clinical results, and not to the number of treatments. Ah! And a policy, transparent for patients, of comparing clinical outcomes between professional teams must be established.

Jordi Varela

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