Friday, December 10, 2010

Health Care: Value, Quality, Cost?

We have been arguing that the health care problem is a result of the Government's interference and is not necessarily inherent in the nature of medicine. The classic example are the life style disease of diabetes (Type 2), heart disease, lung diseases, liver diseases, and STDs are in may ways lifestyle. The individual makes a choice and then we all suffer the costs. How do we get the individuals to pay for their choices? That question is frankly never asked.

Then there are the catastrophic diseases, childhood leukemia and adult brain tumors, and the like, which are critical issues and need the best care and compassion. Now back comes Porter, of the value chain story, and he is opining on health care again. Porter looks at health care as some production vehicle, a manufacturing process, with inputs, measurable processes, and products coming out the other side, with costs assigned to each element.

Porter is quite correct when he applies this to large scale competitive industries. However I believe that he application fails when it comes to health care because of the gross control by Government. Unless of course he is lecturing Washington on how to run a large scale industry. Perhaps.

He states:

Value should always be defined around the customer, and in a well-functioning health care system, the creation of value for patients should determine the rewards for all other actors in the system. Since value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered, and shifting focus from volume to value is a central challenge. Nor is value measured by the process of care used; process measurement and improvement are important tactics but are no substitutes for measuring outcomes and costs.

Since value is defined as outcomes relative to costs, it encompasses efficiency. Cost reduction without regard to the outcomes achieved is dangerous and self-defeating, leading to false “savings” and potentially limiting effective care.

 There is a difference between customer and patient. A customer is often making a somewhat rational choice. Do I need product X from vendor Y or should I make another choice. The customer can often delay gratification or the utility of getting the good but alas that is not the case often in health care. Oftentimes the patient needs a service and has no idea of the "vendor" and further is constrained by all the overhead of the payment systems.

Porter then introduce the quality issue as well:

The concept of quality has itself become a source of confusion. In practice, quality usually means adherence to evidence-based guidelines, and quality measurement focuses overwhelmingly on care processes. For example, of the 78 Healthcare Effectiveness Data and Information Set (HEDIS) measures for 2010, the most widely used quality-measurement system, all but 5 are clearly process measures, and none are true outcomes. Process measurement, though a useful internal strategy for health care institutions, is not a substitute for measuring outcomes. In any complex system, attempting to control behavior without measuring results will limit progress to incremental improvement. There is no substitute for measuring actual outcomes, whose principal purpose is not comparing providers but enabling innovations in care. Without such a feedback loop, providers lack the requisite information for learning and improving.

 Quality is a very difficult if not impossible thing to measure. It is all too often in the eye of the beholder. Porter states that quality is based on following the evidence based guidelines, the CCE world of doing what some GS 9 tells you to do, and with an attitude! In reality quality is treating the patient correctly and compassionately.

Porter finishes with:

The failure to prioritize value improvement in health care delivery and to measure value has slowed innovation, led to ill-advised cost containment, and encouraged micromanagement of physicians’ practices, which imposes substantial costs of its own. Measuring value will also permit reform of the reimbursement system so that it rewards value by providing bundled payments covering the full care cycle or, for chronic conditions, covering periods of a year or more.

 The problem as Porter states is measurement. In the world of quality in the production environment, one learned to measure everything, including all failure modes. The change in manufacturing over the past fifty years was driven by our ability to measure all along the chain in both goods and services industry. Health Care is a far distance from that. The EMR issue is just an example. We see some of the young physicians entering everything they can instead of looking at and listening to the patient. As I have said in the commercial world, "If all else fails, listen to the customer", in medicine there is the Oslerian dictum, "If all else fails listen to the patient".

The EMR as currently structure destroys that capability for many. Thus there is the inherent flaw in looking at health care as some production process, there is no really easy way to gather the data, a prerequisite to measuring and monitoring. The very monitoring interferes with the data collecting and delivery of the service, health care. It is like some quantum effect, that as we try to treat the patient we cannot measure and as we measure we find treating the patient fails.

The concerns I have about Porter's approach is that it fails to understand the practice of medicine. I could and have used his insight in business, I still are conflicted as to how it can be applied in medicine. Perhaps he should spend time with physicians, seeing how decisions are made and understanding the pressures they are under. The new health care law just adds to those burdens.