A Stranger in this World

Redefining Value: A Critique of “Value-Driven Health Care”

Everyone in the world is talking about “value-driven health care.” Or so it might seem if you pick up a medical journal or attend a lecture about health care here in Boston. “Maximizing value for patients” is on the tip of every administrator’s tongue and an interest in cost containment is de rigueur for young physicians who aspire to leadership positions in medicine. For those of us who are intimate with the deep dysfunction of our health care system, improving the quality of care is an imperative. And the realization that health care spending robs from public education and burdens American business makes reducing the cost of health care a top priority across the political spectrum. An approach that allows the pursuit of both of these goals—quality improvement and cost containment—seems ideal and, not surprisingly, has gained broad appeal. So why be concerned about value-driven health care? Let’s start with a little background.

The principle proponent of value-driven health care has been Michael Porter at Harvard Business School. In a number of articles and his 2006 book, Redefining Health Care: Creating Value-Based Competition on Results, Porter lays out the foundational arguments for value-driven care. Neither increasing quality nor controlling costs, he argues, are satisfactory aims for health care organizations. Instead he argues for competition based on value, which he defines as “the health outcome per dollar of cost expended.” Drawing extensively on principles of Lean production, Porter says that value must be measured in terms of the patient’s medical needs over the “entire spectrum of care.” Expenditures that do not contribute to creating value for the patient should be eliminated and efficiency in delivering high quality care should be prized. It has proven to be a persuasive argument. In fact, these principles are underpinning huge changes in the health care system, with tenets of value-driven care having been incorporated into the Affordable Care Act. Accountable Care Organizations are an outgrowth of Porter’s philosophy—their goal will be to provide value for patients over long periods of time in all of the settings where care happens.

Despite all of the excitement about value-driven care, there is a remarkable lack of clarity about what “value” means in this context. Moreover, though providing better outcomes at lower costs may be a noble goal for a health care organization, a system organized around competition to achieve this objective is not functional in a market-based health care economy.

First to the question of defining “value,” a topic that has long been the subject of anthropological thought. David Graeber, in his book, Toward an Anthropological Theory of Value, highlights three way that value has traditionally been discussed in social theory:

1. “values” in the sociological sense: conceptions of what is ultimately good, proper and desirable in human life

2. “value” in the economic sense: the degree to which objects are desired, particularly, as measured by how much others are willing to give up to get them

3. “value” in the linguistic sense, which…might be most simply glossed as “meaningful difference”

Porter’s conception of value in health care is probably most consistent with the first definition. He is arguing that quality, efficiency and low cost are “good, proper and desirable” aspects of a health care system. If Porter’s argument is an attempt to define the values that should be at the core of our healthcare system, it is fair to take a closer look at what he thinks those values should be. He sets them out in a 2010 New England Journal of Medicine piece entitle, “What is Value in Health Care?” The answer is encapsulated in a three-tiered hierarchy,

in which the top tier is generally the most important and lower-tier outcomes involve a progression of results contingent on success at the higher tiers. Each tier of the framework contains two levels, each involving one or more distinct outcome dimensions. For each dimension, success is measured with the use of one or more specific metrics.

It’s a bit esoteric. In short, Tier 1 represents health status gained or retained as a result of medical care. Tier 2 outcomes relate to the recovery process. Tier 3 outcomes represent the sustainability of health.  Examples of how this applies to specific disease conditions can be seen in the figure below. For breast cancer, outcome measures include survival rate, breast preservation, functional status, time to remission and incidence of brachial plexopathy. One can imagine that for diabetes, outcome measures might include mortality, hemoglobin A1c levels, incidence of blindness, amputation rates and so on. This radical reorientation of care toward patient outcomes is refreshing in health care, where factors like physician workflow and the financial interests of provider and payor organizations have more typically been the organizing principles. But how will we decide what is valuable for the patient? Choosing what weight to assign to the numerous indicators that Porter mentions alone would be daunting. What of those that he hasn’t even thought about?

Porter’s conception of value is decidedly focused on the intensive management of illness. Measures of a patient’s emotional well-being, for example, are absent from his framework. So are thousands of other factors that might contribute to a patient’s sense that her medical care has been “good, proper and desirable.” Personally, I value receiving medical care close to my home and from a person I know and trust. Features as diverse as the availability of interpreters, the delivery of culturally responsive care, a family tradition of seeking care at a particular hospital, the appearance of the physical plant, the amount of a patient’s copay or a hospital affiliation with a medical school can all contribute to a patient’s sense of value in their health care. It’s probably obvious that there is no metric for kindness in Porter’s scheme. One can’t help but wonder, will the pursuit of “value” make us proficient at delivering a certain set of outcomes but leave us blind to the more human needs of our patients?

We should also be aware that Porter’s framework alters the tenor of the relationship between health care providers and their patients. As health delivery organizations are rewarded financially for meeting outcome markers, pressure will grow to reach further into patients’ lives. For many patients this will be helpful. But for those who place high value on activities that are in conflict with the goals of the health care system, their autonomy may be at risk. Imagine the patient who wants to eat unhealthy foods, for reasons of pleasure or culture, despite having diabetes, or the patient who refuses surgery for breast cancer or rehabilitation after surgery. This will have an impact on hospital quality measures. Not all health organizations will pressure or abandon these patients, but some will in order to improve their numbers. Some will avoid caring for poorer, marginalized patients if existing health status and patient background are not used to adjust outcome statistics. There will, in a number of scenarios, be distinct conflicts between taking good care of individuals, managing public health and keeping outcome numbers high. Whether we want our health delivery organizations in this position is something that deserves more attention.

It is also completely unclear how competition based on value, defined as the “health outcome per dollar expended,” will succeed in lowering costs. Organizations can certainly succeed in lowering costs internally using Lean production methods, but in the marketplace, health organizations compete on their ability to make money. Making less money is generally a bad competitive strategy. Here’s what I envision happening: An organization that follows Porter’s guide can become more efficient and improve its outcomes, increasing its margins and creating a more “valuable” experience for patients. This will tend to increase its market share and reputation, which the organization will use to negotiate higher, not lower, prices from insurers. Consider the example of Partners HealthCare in Massachusetts, which receives higher rates than any other provider in the state. As our NPR affiliate has reported, Parters

invest[s] in facilities and staff in ways its competitors can’t. That lets it build its brand and market share, which gives it leverage with insurance companies, which lets it charge them higher prices, which they pass on to consumers — and on and on.

Partners controls two large, Harvard-affiliated academic medical centers, numerous community hospitals and thousands of primary care providers. If any organization can provide value across the “entire cycle of care,” it is Partners. But acting in a rational, self-interested way, Partners has driven the cost of health care up. To expect an organization that functions like a business to compete on their ability to drive costs down just doesn’t make sense. Health care providers operate in the realm of economic value, “as measured by how much others are willing to give up to get” their services.

In the end, the greatest shortcoming of the “value-driven” philosophy is not that it is bad strategy for a delivery organization (it isn’t) or that it will be bad for the patient-provider relationship (it needn’t be, if kept in perspective), but the idea that “the biggest problem with health care isn’t… politics.” This is harmful. Determining the basic values that should animate our health care system is a fundamentally political problem. Porter speaks at the level of the business practitioner, but the allocation of resources in health care requires answers to questions about what we value as a society and how we chose to organize ourselves. The notion that these decisions can be made behind closed doors by technocratic experts is hypocritical if the goal is to create value in the broadest sense. To do this, we must put aside the wishes of health industry executives and ask what “community-driven health care” would look like. It’s possible that our patients will value much of what Porter argues for, but we’ll never know if we don’t ask them. 

Sleep/death

Karl Kerchwey once said, to a class of undergraduates, that sleep has power in poetry because it evokes death. Being twenty at the time, I didn’t really understand.

Now I see death frequently. And I work a demanding job. Sleep presents itself as a reminder of choices that must be made each day, about the balance between work, family, friends. 

Though I believe he meant something slightly different at the time—that sleep requires surrender to an abyss, uncertain of the future—I think of Karl Kerchwey sometimes when I’m tired.

What’s unfair about this?

This photo is making its way all over the social media today- I came across it on Facebook. Initially posted three months ago by a Floridian who identifies herself as “M. Turner” on her website, she describes how she was able to get health insurance through the Pre-Existing Condition Insurance Plan (PCIP) that was created as part of the Affordable Care Act. I can’t speak to the veracity of this particular story, but her struggles with the insurance industry are absolutely reflective of the experience of millions of Americans.

I’ve personally been surprised by the number of comments I’ve come across calling this “unfair.” A number of commenters are arguing that Ms. Turner should not be able to get health insurance because she did not “pay into the system” when she was well. This despite the fact that she could not afford health insurance and her job did not provide it. It is a too common argument- blame those who are harmed by a system that is structured against them. Can it actually be true that fairness requires us to deprive the working poor of access to healthcare?

It seems obvious to me that the real injustice is that the richest country in the world fails to provide basic health services to all of the people who live here. And even when we do provide services, we place great financial burden on individuals: according to her website, Ms. Turner is in a significant amount of debt as a result of her medical care and lost her job because of her illness.

Most Americans don’t realize how easy it would be for them to end up in the same situation.

Teaching TLC… and more

“Teaching TLC,” the cover story of the Boston Globe Magazine this week, is about the Cambridge Integrated Clerkship (CIC), the unique program where I spent my third year of medical school. In the piece, Dr. Ishani Ganguli explores some contemporary challenges in medical education and considers how the Integrated Clerkship can help train more humanistic physicians. She writes about the experiences that my classmates and I had over the course of last year, growing close to our patients over time, and highlights data from Academic Medicine showing that CIC students finish their third-year feeling both less cynical and more ready to take responsibility for patients than their colleagues in more traditional clerkships. I’m very pleased that people around Boston will be reading about the CIC and thinking about innovations in medical education. 

A critique of the program raised in the article is that students don’t have enough exposure to inpatient medicine. One expert worries that the CIC “devalues what can be gained [by] being involved in acute care in the hospital, working in a team, [and] coordinating across services.” My response to this is, first, to point out that CIC students have more inpatient exposure than is typically assumed. We regularly take call on the inpatient services and, when our longitudinal patients come to the hospital, we admit them and take care of them there.

I will also concede that there are nuances of inpatient care that I have learned in my fourth year that I didn’t understand previously. But on the numerous acute care rotations I have done since the CIC, I have consistently received positive feedback on my ability to “get my head around a case,” that is, to quickly build a holistic view of a patient. Seeing the same patients at home, in clinic and in the hospital during my third year has made it natural to seek a comprehensive understanding of them and their health. In my view, delaying learning some details of inpatient medicine until my fourth year has been both a worthwhile tradeoff and a natural developmental sequence.

Medical training is so often framed around a particular hospital service or learning to be a particular kind of doctor that the patient experience is forgotten. The CIC gives students a year-long formative experience that is centered around patients. By following them closely, we develop deep empathy with our patients and, more than most medical students, share their experience of their illness. In this way, integrated clerkships allow students to learn to practice in our healthcare system while retaining clarity about its numerous shortcomings.

For instance, I’m quoted in the article saying that CIC students are able to “see how people with complex illnesses keep bouncing around, how they experience fragmentation of services.” Up-close and longitudinal exposure to this problem is essential for medical trainees. We know that five percent of patients account for fifty percent of healthcare costs and that care fragmentation plays a large role in this. If the integrated clerkship model can inspire physicians to address this issue by building better systems for care coordination, its impact will be enormous.

My personal hope is that by exposing students to patients’ lives, to the communities in which they practice and to the limitations of our healthcare system, that we’ll do more than create skilled clinicians who show more TLC. I hope we that can train more socially-conscious physicians, truly capable of addressing the big problems that American healthcare faces.

Occupy Wall Street & Inequality

I’m at a conference this morning and just heard a fantastic talk from Dr. Kate Pickett. She is a social scientist who researches income inequality and its effect on society. She presented the graph above which shows the correlation between income inequality and a number of health and social ills. The index includes low life expectancy, poor literacy, infant mortality, homicides, imprisonment, teenage pregnancy, obesity, mental illness, drug use and poor social mobility. She also has figures that link the prevalence of each individual problem to levels of inequality in a society. The media has been making a fuss about the diversity of causes represented at the Occupy protests, but it seems to me like there’s a pretty obvious unifying explanation. 

Missing longitudinality

This month I’m on my sub-internship, where fourth-year medical students do their best to act like interns (first-year medical graduates) and take care of patients on the medical service. It’s been fun, fast-paced, a lot of work and a steep learning curve. I feel like I’m getting the hang of it and, as my efficiency improves, will be able to really enjoy it.

Still, I already miss seeing patients for longer than a few days. Our patients come to us to have an acute issue stabilized- most of their care is handled in the outpatient setting. I find myself wishing that I could get to know them better and go to their follow-up visits to see how their illness progresses or resolves.

This was the Cambridge Integrated Clerkship model. It not only allowed us to build relationships with patients over time, but it gave us the chance to see the full course of an illness—something that rarely happens in the era of the two day hospital stay.

Medical student indebtedness and career decisions: values matter too

Pauline Chen has a compelling piece on the NYT Well Blog today about medical student debt and it’s unappreciated costs. It draws on a recent publication in Academic Medicine which highlights the diverse drivers of medical student indebtedness. These include an expansion of the medical school’s research enterprise, a lack of accountability on the part of medical school administrators, who can increase tuition to support the research mission, and the advent of medical students who want to live like young professionals not professional students.

Dr. Chen argues that high levels of medical student debt are, at least in part, responsible for the shortage of primary care doctors and those willing to take care of poorer patients. She writes that “looming debts mean eschewing a calling to serve a particularly needy, less lucrative patient population or practice, and instead pursuing a well-compensated subspecialty that caters to the comfortably insured.”

I’d like to suggest that something more complicated is going on. As both articles point out, high medical school tuition acts as a deterrent to students from underrepresented minorities and lower socioeconomic status. Since the 1970s, enrollment of underrepresented minorities in American medical schools has stagnated (see figure). The percentage of students coming from the lowest 40% of the income spectrum has dropped from 27% to 10% from 1971 to 2004. The percentage of medical students from the top 40% of earners has increased from 66% to 75%. Our profession is increasingly made up of people who come from the upper and upper-middle classes.

As this AAMC report points out, “physician diversity contributes to increased access to health care for underserved populations.” The converse is true as well— the less our profession represents the demographics of the U.S. population, the less well we’re able to care for it.

No doubt, students are justifiably concerned with their debt burdens, but it’s frequently forgotten that one can make a good living in primary care or caring for the underserved. Personally, I wonder if students eschew this work because of their loans or if they never really consider it in the first place. A recent study highlights that sustaining a practice in an underserved area requires a deep personal motivation or strong sense of identification with the community. If most students don’t bring these characteristics to medical school, and schools don’t nurture them, it’s no wonder that students choose lucrative subspecialties where their income can keep pace with their peers outside of medicine. 

This is all just to say that increases in tuition and debt for medical students are only a part of the problem. They reduce our ability to recruit and train a diverse workforce. This in turn contributes to skewed values within the profession—and it is our values, not the debt itself, that most frequently drives graduating doctors into subspecialties and suburban practices.

Language training for health professionals: an opportunity

During my first few years in medical school, I helped to launch the Harvard Medical Language Initiative (HMLI). The group was created to meet the demand among my classmates for language training during the academic year (it had previously been offered only in the summer for fourth year students). We inherited a Spanish course from the class ahead of us and during my time at the HMLI a committed group of students worked to strengthen that foundation. We found faculty mentors to teach the courses, we worked with the Dean for Medical Education so that faculty could cite their teaching in their promotions portfolios and we worked with the Office of Diversity and Community Partnership to secure grant funding. We expanded to offer courses in Portuguese and Mandarin (covering the top three languages in Massachusetts, after English) and we won recognition for the courses as official Harvard Medical School electives. These all felt like huge accomplishments.

As more of our classmates took the courses, we started to wonder about our impact. We became concerned that graduates might misinterpret finishing the course as a measure of fluency. We read an article in JAMA that highlighted concern about “physicians and medical trainees [who] underuse professional interpreters… substituting their own limited spoken Spanish during clinical encounters.” Could we be contributing to the problem?

We started to design our curriculum to address these concerns. We incorporated more simulated patient encounters, we introduced cultural sensitivity training into the courses, we had Interpreter Services from one of our hospitals train the students on the importance and proper use of interpreters. We tested students more and talked frequently about knowing one’s limits. I dreamed that we could have our students undergo something like Interagency Language Roundtable testing, to rate their proficiency in a language. Funding proved to be an obstacle for the last idea, but I believe that we succeeded in making our students more self-conscious about their language skills.

The busyness of third-year has separated me a bit from the HMLI. A new generation of students is in charge and, I understand, doing a fantastic job. Though I remain concerned about the outcomes from language training for health professionals, I’m still a supporter. Healthcare is a field driven by skills and competencies; it is natural for providers who want to take good care of a diverse patient population to seek to learn another language. The key is that this be taken as an opportunity to train students in cultural sensitivity, interpreter use and critical self-assessment of their language skills.  Very few people will come away from a language course with anything close to fluency in Spanish, Portuguese or Mandarin. Everyone, though, can learn to take better care of their patients with limited English proficiency.

Disappointed

In 2008, I drove to New Hampshire and knocked on doors all over the state. I wrote letters to my hometown newspaper in Pennsylvania, arguing that electing Obama would improve our healthcare system. I flew to Washington for the Inauguration. Since then, when friends have argued that Obama should be bolder, I was the one who defended him. This is a conservative country and progress is slow and hard, I would say. Yes healthcare reform should have gone farther, yes the stimulus could have been bigger, yes we need a better financial regulatory law, but the direction of the country, at the very least, was right.

With his offer to cut Medicare and Medicaid, Obama has changed course dramatically. This represents not slow progress, but a giant step backwards. Paul Krugman has explained the negative effect that the Medicare cuts would have. I mentioned recently why I oppose the Medicaid cuts. Here I just want to express my disappointment. We need a President who is willing to stand up for the safety net and explain the vitality of these programs to the American people—not one who starts by offering deep cuts.

The past weeks have made me rethink my defense of Obama. The Republicans clearly think he’s a pushover in negotiations. What if it’s because he has been all along?