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Samenvatting Literatuur Keuzevak Value Based Healthcare (GW302)
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This document contains a summary of all literature from the Value Based Healthcare elective course.
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Abstract literature VBHCWeek 1
Value-Based Health Care Delivery – Michael E. Porter
The challenges of delivering health care in the United States are receiving growing attention as costs
continue to rise and evidence of uneven quality accumulates. These problems are not unique to
America but are raising concerns in many countries, even those with universal insurance coverage.
My work has examined the structure and organization of health delivery viewed from a value
perspective, where value is defined as the health outcomes achieved per dollar spent.
To achieve a high-value health care delivery system, universal coverage is necessary but not
sufficient. Universal coverage is essential not only for equity but also for efficiency. The lack of
universal insurance in the United States creates much inefficiency, including those that arise from the
distortive effects of cross subsidies to cover the cost of serving the uninsured and the failure to
provide timely care in cost-effective settings. However, the fundamental problem in health care is the
value created by the delivery system. No matter who pays, the core issue is value. Unless the value of
delivery increases significantly, universal coverage will only make the problem worse. The major
problem in health care delivery is not a lack of hard work, commitment, skill, or even inadequate
medical science, although science can surely improve. The main problem today arises from the
structure of health care delivery, or how the practice of medicine is organized, managed, measured,
and paid for. Substantially increasing value will require a transformation in how health care is
actually delivered.
The question we must ask, then, is how do we design a health care delivery system that will
dramatically improve value? What structures, processes, and policies would maximize the value
delivered for the patient and encourage continuous improvement? Medical science is constantly
changing, and we need a system that is dynamic, assimilates new ideas, and improves rapidly.
Currently we are trying to deliver 21 st-century medicines with 19th-century organizational structures,
management processes and measurement systems. In every other field in which I have worked,
some level of competition was necessary to drive restructuring and value improvement. This is true
in health care as well. However, today competition has a bad name in health care, as it should.
Today’s competition in health care does not equate with value for the patient because financial
success for system participants does not equate with success for the patient. Health plans, for
example, can achieve success by selecting healthier subscribers, imposing copays on medications,
and bargaining for larger discounts, none of which actually improves the health of their members.
Physicians can achieve success by scheduling more visits and performing more procedures, whether
or not they produce better patient outcomes.
The market system is not failing in health care, it is how the health care market has been structured.
Today’s competition is what we call a zero-sum competition, or a competition to divide value rather
than to improve it. When a hospital system buys primary care practices to guarantee referrals, this
does not create value but redivides it. When a health plan exercises bargaining power to extract
better prices that have nothing to do with the true costs of caring for the patient, it does not create
value but redivides it. Unfortunately, consumer-driven health care has become the latest example of
zero-sum competition, because it is mostly about cost shifting to patients. In today’s system, each
participant is pitted against the others to shift cost or capture more revenue. Health care delivery will
not reach its full potential until all the actors begin working together to increase value and get
rewarded accordingly. In a value-based system, all the actors can win, including the patient.
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,The Goal of Value
The first essential principle in creating a high-value delivery system is for each participant to define
value as the goal, not reducing cost, maximizing revenue, or providing every service. Improving value
requires improving outcomes per unit of cost. Pursuing cost reduction as the goal creates a trap; the
more the focus is on reducing costs, the more costs have gone up. Many steps that cut cost, without
considering value, end up leading to higher costs in the long run because they forgo smart
investments or only postpone costs or move them to somebody else. Better health is inherently less
expensive than poor health. Thus, the faster individuals achieve or regain their health and sustain it,
the lower the true costs in the system will be. Better health outcomes have a powerful effect on costs
in the long term. Earlier detection, correct diagnosis, appropriate treatment, less invasive treatment
methods, and other steps that improve outcomes can also dramatically lower direct costs, not to
mention the indirect costs of poor health, such as lost work time, immobility, and others. Quality
improvement is the best way to produce fundamental cost reduction, but the system is not
structured to achieve or reward improvements in outcomes.
Organizing Around Medical Conditions Covering the Full Cycle of Care
What does a high-value delivery structure look like? The second essential principle of value-based
delivery is that care should be organized around the way value is actually created. Today, the system
is organized around specialties, departments, interventions, and individual facilities, but value is
actually created in the total care of a patient’s medical condition over the full cycle of care. A medical
condition, such as diabetes or breast cancer, is an interrelated set of patient circumstances best
addressed in an integrated manner. The definition of a medical condition includes common co-
occurrences, for example, diabetes is related to eye issues, vascular issues, and kidney issues among
others. For any medical condition, such as a headache or breast cancer, there is also a cycle of care
that involves a long series of activities stretching across months and, perhaps, even years. Surgery is1
part of the care cycle, but usually a small part. Care for a medical condition should be organized into
integrated practice units (IPUs), which include all the necessary skills and specialties, including those
needed for co-occurring problems. Surgery is a procedure, not a medical condition. Surgeons may be
part of an IPU, but do not alone determine value because they depend on others before and after
surgery for the ultimate success of the patient care. In an IPU, care does not occur sequentially but
involves parallel processing. There is a common administrative structure, and facilities are designed
so that all necessary facilities and technology are in 1 place and everyone’s time is used efficiently,
including the patient’s. All the information involved in the care cycle is captured and stored in one
place and is transparent to everyone.
The IPU model involves integration across the specialties but also integration across time. To display
the cycle of care, we use a framework we call the care delivery value chain (Fig. 1). The care delivery
value chain for any medical condition starts with prevention and screening, leading hope-fully to
early detection. The care cycle ends with ongoing management of the disease. Breast cancer patients
who have successful therapy, for example, must often be managed for long periods of time because
breast cancer has unfortunately become a chronic condition for many patients.
The current health care delivery system is not organized around care cycles, but individual, discrete
interventions. Outpatient care is separate from inpatient care. Specialties deliver care in separate
units. Drugs are managed and paid for separately from service delivery. Rehabilitation is a different
world than acute care. The current structure cannot possibly produce the best outcomes.
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,Figure 1: The care delivery value chain for breast cancer
Care delivery in an IPU structure is truly integrated. Just because services are colocated does not
mean care is integrated. Just because providers are in the same building does not mean care is
integrated. Just because care is delivered by the same hospital system does not mean it is integrated.
Just because a hospital creates a cardiac center or a cancer institute does not mean that it is an IPU,
or that care is integrated. Unless the organization, management, and re-imbursement of providers
are restructured around medical conditions, value improvement will be severely constrained.
Although lean production, evidence-based guidelines, and safety processes can make practice more
consistent, mistakes less likely, and handoffs a bit more efficient, value improvements will be
incremental. Until organizational structure is aligned with value and around the patient’s medical
circum-stances, instead of around doctors, specialties, and interventions, progress will be limited.
Some patients will have multiple medical conditions. Common co-occurrences are part of an IPU.
Every excellent diabetes IPU, for example, should have vascular, cardiology, ophthalmology, and
nephrology team members. Where a patient has co-occurring conditions that are uncommon,
however, patients will be cared for by more than one IPU. In the IPU structure, however, patients
with multiple medical conditions will need just one point of coordination for each condition. This
contrasts sharply with the current system in which numerous individual specialists must coordinate
one-on-one with each other and indifferent ways for every patient.
When care delivery is organized into IPUs, powerful scale and experience benefits create a virtuous
circle (Fig. 3). As a provider team achieves volume and experience in a particular medical condition,
whether it is head-and-neck cancer, Type I diabetes care, or cardiac care, major value benefits occur
as is becoming more and more apparent in the medical
literature.
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, Experience and scale allow dedicated teams or groups of people working together every day to
provide a particular kind of care. Health care delivery today is full of temporary teams that come
together around a particular patient but then reform into other teams around other patients with
different problems. Thus, opportunities for value improvement are severely constrained. Value is
maximized by dedicated teams in which people work together every day to improve their ability to
address a particular set of problems, recognizing that it is their collective effort that determines the
overall result.
Value must be Universally Measured and Reported
The third essential principle of value-based delivery is the need to measure value. Without measuring
outcomes and costs at the medical condition level, it is difficult to improve, even with the best of
intentions.
Today measurement focuses on interventions, departments, and hospitals, which are not the
appropriate value unit. Measurement is dysfunctional in large part because organization is
dysfunctional. What is measured is what is easy to measure, and what is billed for. Only by measuring
patient outcomes over the cycle of care for each medical condition will it be possible to optimize
overall value for the patient and to drive value improvement. Outcome measurement must capture
the set of out-comes involved in caring for any medical condition. There is not one outcome, such as
the survival rate, but a hierarchy of outcomes for every medical condition. A first tier of out-comes
has to do with the health status achieved for a patient. A second tier captures outcomes relating to
the care itself: How uncomfortable was treatment; how fast was recovery achieved; and how many
and what kind of complications were involved? A third tier of outcomes involves sustainability. How
long did the patient maintain the health improvement achieved, and what were the long-term health
consequences of the therapy itself?
Outcomes need to be adjusted for patient initial conditions. Failure to control for initial conditions
leads to “cherry picking,” or the incentive to select healthier patients at the expense of those that are
more challenging. Research on the link between initial conditions and outcomes is essential, nota
distraction, because it informs the factors that affect the success of care and reveals avenues for
learning and innovation.
Reimbursement should be Aligned with Value and Reward Innovation
A fourth principle of value-based health care delivery is to align reimbursement with value creation.
Today, reimbursement takes place for discrete services, not for care cycles. For example, separate
reimbursement occurs for out-patient and inpatient care even though the two are part of the same
care process. This works against value, by creating disincentives to reduce the need for or complexity
of care. Value is created by the entire care cycle, not the parts. We must start paying for care cycles,
not for discrete interventions. This will require bundled reimbursement for medical conditions— or
medical condition capitation— based on severity. Ultimately, society and the patient do not care
about the costs of the parts, but the total of the care cycle and the value achieved.
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