Monday, 1 December 2014

High Value Healthcare: Porter and Lee proposals

Michael Porter, professor at Harvard Business School and Thomas Lee, Medical Director at Press Ganey, an organization aimed at improving the patient healthcare experience, published an article on the HBR Blog Network:  "Why health care is stuck and how to fix it". These two teachers, tired of analyzing the stubborn (and chaotic) reality of the American healthcare system, have decided to focus on making strategic proposals to change things.

How can it be that with so many good and well-intentioned people involved in reforming the American health system, they can’t find a solution? Almost the opposite happens: it seems that the opposing positions are increasingly reinforced.

The authors ask this rhetorical question, although they, far from disenchanted, still insist on the idea that solutions can only be systemic, as this is where the problems lie in the model.

The solutions proposed by the authors are indisputable, but not sufficient without a genuine desire for change. Let's review them: clinical management units, measuring patient outcomes and costs, changes in the pattern of payments to suppliers, service integration, promotion of "franchises" of services that work well and a system that facilitates the information system. You will agree with me that this is a coherent recipe that, at least in theory, we all approve of.

But Spain is not America and therefore it’s not a case of applying their medicine, but instead I want to echo point 4 (integration of services) because I think it's a relevant and complex point here and there. Reviewing another article by the same authors "The strategy that will fix health care", I chose four visionary concepts that ought to promote integration of services a lot more than today's timid attempts.

Point 1: Concentrate the volume of case mix in fewer locations
People are now more likely than before to travel in order to find quality and results. Moreover, in the world of service providers, it is known that from a certain degree of complexity, the philosophy of local services is a trap. Although traditional thinking of hospitals intends to solve everything, society’s mindset shift is unstoppable and henceforth providers will only be able to offer services that are able to demonstrate competitive clinical outcomes.

Point 2: Choose the appropriate location for each service
In the same way in which hospitals that do not have vascular intervention cannot admit patients with a heart attack, we should not allow the practice of paying for medical-surgical services of medium and low complexity in university hospitals, with all the tariff burden and inefficiencies that this implies.

Point 3: Offer integrated services in different locations
Cooperative networking, common today, may yield some advantages, but make no mistake, it is not integration. According to the authors of the article, to be able to talk of integration, clinical work needs to be involved despite the geographical distance, team-feeling, rotations, unique clinical practice guidelines, clinical sessions and a lot of evaluation in order to correct and improve. As an example of service integration I remembered the dialysis service at the Puigcerdà Hospital which is an extension of proximity to patients living in that Pyrenean region but is clinically led by the nephrology department of Althaia Manresa.

Point 4: Redefine the portfolio of services based on results
Fighting the status quo that insists on preserving the current practices especially at the two ends of the complexity of the case mix. Let's look at an example of how a teaching hospital could redefine their services:

In the graph, drawn up by myself; point 1 would be health activity of care to acute exacerbation of chronic patients who may be susceptible to agreements with other, more appropriate devices. Point 2 would be low complexity surgical activity that could be solved by more adequate operating rooms in both circuits and resources. Point 3 could be illustrated by the stroke code (ictus code) which, in order to improve clinical outcomes, has forced many hospitals to stop treating these patients. Point 4 shows how the same centre that has lost the stroke code (ictus code) could fight to obtain a transplant service which would absorb other services from other centres, thus being able to increase their cases and improve results.

Surprisingly as Michael Porter, defender of competitiveness, when assessing the health sector details: competitiveness in clinical outcomes, but not in health activities. And the detail is not trivial.

Jordi Varela

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