Value-based healthcare: what comes next?

Alexandre Lourenço

More than 15 years have passed since the publication of Michael Porter and Elizabeth Teisberg's iconic book Redefining Health Care.

As a seasoned consultant, Porter delivered a simple message: Value-Based Healthcare (VBHC), an attractive concept to healthcare professionals, providers and payers. Presented as a solution to the health care crisis in the United States, the concept of value – the relationship between results and the cost to achieve them – quickly spread throughout Europe, South America and Australia. Like a magic potion, it provided a solution for almost all health-system problems: addressed fragmentation, variation, over-provision of care, financial lack of sustainability, medical errors, clinical compromise, lack of trust, patient disengagement, etc.

Humanism and reasoning versus cookbook medicine

Soledad Delgado
 

From "criaderas" to "soleras"

At the onset of autumn, my land fills with the smell of must. Freshly extracted from the pressed grape, it ferments and then passes to American oak barrels for ageing. The containers are stacked at three levels. From the lower one, the "solera", a third of its content is extracted for consumption. That part is filled with wine from the intermediate level, the first “criadera", and the same happens with this one, which receives wine from the upper level, the second “criadera". It's the one who receives the fresh must, full of life and potential. This wine, still young, is mixed during its ageing with matured wine, from which it takes some characteristics and to which it gives back the freshness of new aromas and flavours. The two wines are enriching each other, sheltered by the flower veil that promotes biological ageing. 

“Noisy” healthcare decisions

Pedro Rey

Daniel Kahneman

A few months ago, Paco Miralles published in this blog "In medicine, there is too much noise", where he reviewed the latest book by psychologist and Nobel Prize winner in Economics Daniel Kahneman (together with Olivier Sibony and Cass Sunstein) Noise: A Flaw in Human Judgment. Since Paco himself suggested that the issue of noise in decision-making "could provide for several posts", I decided to make a slightly more extensive critique of what the reader will find in the book.

Healthcare must be imbued with value

Paco Miralles
 

The 22nd National Congress of Hospitals and Health Management featured an organizational success that augurs a certain post-pandemic "normalization"; many congressmen and a program with a significant presence of value-based medicine. I take this opportunity to congratulate the organizing committee for the great work done.

Much has been said about the paradigm shift in the healthcare system, about the need to do things differently, about value as a solution for humanization, for the cohesion of professionals, for the alignment of funders and providers, and for the sustainability of a system in which without value everything is much more expensive.

Baker's Decalogue for high-performance healthcare organizations

Jordi Varela
Editor

 

Americans trust that competitiveness is the essence of human activity, which has made them the world's leading power, with China's permission. This principle, however, has not worked for them when they have applied it, without palliative, to their health care system, which is showing clear signs of poor performance: it’s very costly, it’s inequitable and it’s showing poor results. For this reason, some public health care organizations such as Veterans Affairs and Medicare, or private, such as Mayo Clinic, Cleveland Clinic or Kaiser Permanente, are trying to put sanity, analyzing what are the keys to improve the performance of the system.

Providing courage, balance and humanity in the emergency services

Nacho Vallejo
 

@varelalaf

Urgency is a unique environment in healthcare. It works intending to deal with situations that can put the person's life at risk, but it’s also a "safety net" or, as we have defined it on some occasion in this blog, "a refugee camp of the health system". The care for people in this field of health isn’t only due to pathological and physiological disorders, but sometimes those who go to the emergency room do so as a consequence of dysfunction of our healthcare system that manifests itself with "collateral damage" derived from poor accessibility and, in other cases, from an excess of activity.

Medicine must be value-based

Paco Miralles

Many of us believe that medicine in general and doctors, in particular, should direct efforts to provide patients with value services. This approach would leave even the profane flabbergasted: but do doctors not do for their patients that which gives them value?

It's important to know the past to understand the present and outline the future. For a few decades, we have acted based on evidence-based medicine, a movement that led to the transition to a methodologically neater practice. Assistance based on tradition and empirical experience would succumb in the face of well-structured studies. This revolutionary concept led him to be nominated as one of the ideas of the year 2001 by The New York Times.

Medicine, values and communication

Salvador Casado

Modern medicine has achieved a spectacular development in the last century in parallel with the rest of society. Spurred on by science and technology it has managed to overcome ambitious goals and shines proudly on the basis of its achievements. Unfortunately, there is a long shadow that contains burdens and threats. Inequalities in health, overdiagnosis and overtreatment, iatrogeny, the progressive dependence of citizens on health systems are increasingly present realities.

Illustration by Paula Alvear, from the poems Arconte Enfurecido

On the other hand, private health systems and the enormous conglomerates of pharmaceutical and technological industries based on profit seek interests that are increasingly distant from the common good. In the face of these interests, public health systems are slowly collapsing due to under-funding, cutbacks and the chronic overloading of their professionals. Everyone agrees on the complexity of managing alternatives but no one dares to implement them. Meanwhile, the public health systems are melting like butter as services are outsourced, professionals working conditions get worse or units are reconverted and closed (Public Health and others).

Escape the biomedical bubble

Cristina Roure

One of the most recurrent citation in clinical management is the Porterian concept of health value, which must be established based on the interest of the patient and not the rest of agents, read professionals, managers, researchers, administration, biomedical industry, etc. According to this concept, the ultimate purpose of research and innovation in health should be to provide maximum benefit to patients and society. However, as I commented in my last blog post, I often prioritized research and the real needs of patients, but society goes in different ways.

Narrative, expectations and relevant outcomes for patients

Gustavo Tolchinsky

At the beginning of my medical residency, I used to experience some frustration with some patients whom, despite having gone through a correct assessment and having been diagnosed with a treatable and straightforward pathology, when they were discharged, they were still not satisfied. After some time, I began identifying that at least one of my mistakes was in my approach to patients. Excessively focused on diagnosing a pathology as if I were to “nail it” in an exam, I wasn’t paying attention to what led the patient to visit me, their concern; this couldn’t be solved by giving a mere diagnosis and treatment. When we go through these situations, we find it traumatic, frustrating and disconcerting. On top of that, this may lead to over-acting that only leads to over-treatment due to repeated patient demand at different points of the system. This could be because the clinical solution we offer does not solve those concerns that went unidentified in the clinical interview, or that the patient's expectations are ill-adjusted to realistic results and these, therefore, are unattainable.

For a research based on value. The failed model of antibiotics

Cristina Roure

As we have commented on some occasion in this blog, neither the price nor the volume of investment in R&D of the medicines corresponds to the value they provide. Antibiotics, along with vaccines, have saved millions of lives, have allowed to address challenges such as transplants and complex surgeries with guarantees of success and, if this were not enough, they also add enormous value to the productivity of the agricultural sector.

Measuring the effectiveness and value of clinical practice

In the "XIV Conference of the Sign Foundation", Jens Deerberg-Wittram, Director of the Boston Consulting Group, gave the inaugural lecture entitled "From volume to value". It was a very timely speech, at a time when the obsessive control of budgets and waiting lists prevents clinicians and managers from reflecting on what contributes so much care activity to society. The concept of value expressed by the German speaker is very new for healthcare managers, who tend to understand clinical effectiveness as a rhetorical concept more typical of epidemiological studies.

The excesses of image diagnostics

The practice of modern medicine is subject to much pressure from the use of diagnostic imaging technologies, many of which are truly dazzling for the eyes of clinicians and patients and, as a result, health budgets are constantly increasing. This being the case, everyone agrees that more professional debate should be generated to put the matter in its place and avoid the excesses that damage resources, irradiate people and don’t add value to clinical reasoning.

Cumulative complexity and minimally disruptive medicine

The clinical model based exclusively on the diagnosis and treatment of chronic diseases is precipitating medicine to fail. Addressing complex realities from partial positions is, at least, unfortunate, and despite this evidence, health care systems continue to finance the fragmented provision of services. Mary Tinetti and Terri Fried warned us in 2004, in "The end of the disease era", that it should evolve towards a bio-psycho-social model, prioritizing the integral evaluation of each person, adjusting the therapeutic plans to each reality and offering integrated services. The analysis was timely except that the authors were wrong when they predicted that, the old model would end with the advent of the new century.

Financing models do not promote value

The budgets of public health systems and those of private insurers are highly pressured by the constant emergence of new drugs, such as direct-action anti-virus to cure hepatitis C, or new technologies such as transcatheter aortic valve implants (TAVI) and logically the funders expend a lot of energy in limiting the use of these innovations. The battle, needless to say, has a predictable outcome because the conjunction of investors with the beneficiaries is usually lethal to the guardians of health expenses. An article based on American healthcare, emphasizes the waste induced by the "low cost" rates (if you are interested in the subject, I leave a second related link). The issue explained in Health Affairs  would take the opposite extreme as instead of "very little but expensive activity", this analysis focuses on "a lot of very cheap activity" and, it sounds untrue, but, at least in the US, at this point there could be more waste.  

Medical Schools: reductionism versus empiricism

Competitive eagerness has reached the medical faculties and now produce batches of new doctors with a higher scientific preparation, priorities arranged by factor of impact, a competitiveness for research funds and, to a lesser extent, clinical practice. Young doctors know that in order to fight for the most coveted places they must show a resume full of publications, while the clinical skills, although present, will not be the differential element. What is observed, then, is that the educational reforms driven by academic success.

Radiologists and incidental imaging findings

A group of radiologists from several American university hospitals (Massachusetts General, Cleveland, Brigham and Women's, etc.) started a debate in the Journal of the American College of Radiology about the eventuality that radiologists would stop reporting the incidental imaging findings lacking clinical significance. "The traditional role of the radiologist," they say, "is to warn of everything they see, leaving the interpretation of the findings’ relevance to the referring physician”. However, we now open the opportunity to go further, and not just intervene by saying, for example, that an observed abnormality is benign, but also taking the decision not to report the milder ones, given the possibility that our opinion generates confusion and ends up causing excessive medical actions".

Regarding level I renal cysts of the Bosnian classification

The radiologists who authored the article used the findings of renal cysts, which are very frequent with a prevalence of 36% in patients over 80 years of age, in order not to inform of renal cysts of level I of the Bosnian classification in their reports, in accordance with the following criteria: a) the cyst is not the reason for the examination, b) doesn’t generate local problems, c) has no malignant potential, and d) is not likely to generate a polycystic kidney disease.

Medical schools: reductionism versus empiricism

The current competitive drive has reached the medical schools to the extent that it now delivers batches of new doctors with higher scientific preparedness whose priorities are influenced by their impact, competitiveness for research funds and, to a lesser extent, clinical practice. Young doctors know that in order to fight for the most coveted positions they will have to show a curriculum full of publications, while the clinical skills, although present, will not be the element that differentiates them. What is apparent is that educational reforms are part of the mechanism which is focused on academic success.

The induced gray areas

From scientific points of view, one tends to think that the clinical practice is binary. That is, it’s thought that the medical actions are either effective or ineffective. The reality of the practice teaches, however, that on the ground, the gray zone is much broader than one would hope because many clinical practices are neither clearly effective nor clearly ineffective. In an article in The New England Journal of Medicine, "Addressing the Challenge of Gray-Zone Medicine," Chandra and colleagues claim that due to the dazzling effects of new drugs and technologies, the gray area is expanding and therefore, these authors claim strategies to reduce the phenomenon.

Proximity versus quality

The proximity of the health services is a highly appreciated and defended value; not in vain regional hospitals have proliferated throughout the country as an essential instrument for territorial balance. The local organizations and the small communities have understood this and have protested fiercely against any councillor who has dared to suggest that it might be convenient to close some low-performing service. It seems generally accepted therefore; that the proximity of services is a value that favours the accessibility for dispersed populations and improves the equity of the system. However, it doesn’t escape anyone that too often, maintaining the quality of certain services when located far from the centres of reference is a challenge in itself.

This reflection has come to my mind after reading an article in the New England Journal of Medicine by Michael Porter and Thomas Lee "Why strategy matters now". One may rightly say that this source is a little far-fetched for the dilemma that I raised, especially and fortunately because the problems of our health system are very different from those of the North American system, but in return, I’ll insist that after rereading it, it seemed to me that the recipe of the two authors from Harvard can be useful in offering rational elements to the controversy around the proximity – an issue that always seems to be politicized.

Let's consider Porter&Lee’s 6 strategic proposals that can be tailored to our concerns:

1. The main objective of any strategy must be the value it brings

To give a couple of examples, in a strategy of chronic disease, community work is a value in itself; on the other hand, for the infarction code, the efficacy of clinical action is the tracer axis, so the planner must know how to balance the dispersion of the services with the excellence of the results.

2. Organization charts must be redesigned according to the needs of patients and processes

We ought to abandon the current organizational charts based on bodies, systems and levels of care and advance to multidisciplinary teams that are organized according to the needs of patients, who are responsible globally for clinical processes and that are accountable according to the value obtained ( remember that Porter’s value is the relation between clinical results and costs).

3. The portfolio of services must be adjusted to the organization’s capabilities 

In order to fulfil the main objective, hospitals must identify the services in which they are able to provide value, declining to maintain an offer that doesn’t correspond to their real possibilities or to the desired results. This adjustment is valid both for the regional hospitals’ historical difficulties in retaining talent, as well as for mid-level centres that despite all reason, focus on tertiarism as a sign of identity.

4. Clinical management units should be oriented to clinical effectiveness

The multidisciplinary teams must evolve towards "integrated" clinical management units when they have the capacity to approach a sufficient number of patients and the results obtained are good enough. In this situation, the units must be endowed with the essential resources, and even financing models based on adjusted capital or objectives, as the case may be.

5. Synergies can solve many of the current problems

To overcome the problems of excess installed capacity, duplicities, or the desire to act beyond the real possibilities, organizations must have the vision of generating synergies to solve these imbalances. Concentrating services to a single point or sharing professional teams are two strategies that, when they have been implemented rightly, yielded good results.

6. The referring hospitals must elaborate more strategies by looking at the territory

We ought to further deepen the current strategy of opening referring hospitals in the territory, with all kinds of agreements with hospitals of lower hierarchies. In the same way that it’s not good for regional hospitals to practice tertiarism, it’s also unreasonable for referring centres to dedicate their costly structures to solving case-mix typical of community centres.

It would be advisable that we take advantage of the lessons of Michael Porter and Thomas Lee in order to overcome the dilemma of proximity versus quality, generating more professional and social debate about the value of health services, since it’s pointless to have an emergency unit at every corner if we can’t support them, every day of the week and all hours of the day (and night), with qualified professionals.

Jordi Varela

Editor