The Danger of Silence: A Loud Rebuttal to Michael Porter s Value-Based Health Care Delivery Proposal

The Danger of Silence: A Loud Rebuttal to Michael Porter s Value-Based Health Care Delivery Proposal

Authors and Disclosures Borthakur, Gitasree, M.D. 1 Kerridge, William, M.D. 1 Ballenger, Zachary, M.D. 1 Gunderman, Richard, M.D. 1 Department of Radiology 1, Indiana University School of Medicine, Indianapolis, IN *None of the authors have any disclosures.

The Challenges Ahead How do we address the financial costs of healthcare? Healthcare costs are rising Reimbursements are declining How should we better coordinate care for patients? How can the redundancy in patient care be eliminated? How can we improve continuity of care? How do we sustain the field of radiology? How do we prevent commoditization of our jobs? How do we demonstrate the value of radiology?

The Proposal www.sharedvalue.org Michael Porter, the Bishop William Lawrence University Professor at the Harvard Business School, formed a strategy to transform the current healthcare system. THE STRATEGY FOR VALUE TRANSFORMATION: Consumer Driven Healthcare Healthcare focused on the volume of services provided Patient Outcome-Based Healthcare Healthcare focused on the outcomes achieved by patients for the lowest cost

2014 ACR AMCLC Moreton Lecture: Value Based Healthcare Delivery We have to measure value by the set of outcomes that matter to patients. www.acr.org -What are the implications for radiology? -What questions should we ask? -How should we respond? www.acr.org

Organize into Integrated Practice Units (IPUs) Build an Enabling Information Technology Platform Expand Geographic Reach 5 6 1 COMPONENTS OF VALUE BASED HEALTHCARE DELIVERY 4 3 2 Measure Outcomes and Costs for Every Patient Move to Bundled Payments for Care Cycles Integrate Care Delivery Systems

1 Organize into Integrated Practice Units (IPUs) The IPU is composed of clinical and nonclinical personnel who provide for the full care cycle for a patient s medical condition. THE PROPOSAL: Value is added by centralizing patient care into large units that provide high volume services. Let s look at an example provided by Porter The basic Diabetes IPU. This would require services of physicians, mid-level providers, and nurses of the following departments: Endocrinology Nephrology Ophthalmology Vascular Surgery Interventional Radiology Physical Medicine and Rehabilitation Infectious Disease specialists Radiology Pathology Emergency Department THE REBUTTAL: This looks like a hospital The patients who contribute most to the financial burden of healthcare delivery often require multidisciplinary resources and facilities of hospitals

2 Measure Outcomes and Costs for Every Patient THE PROPOSAL: Although measuring healthcare outcomes is not a novel idea, this new proposal suggests that we measure outcomes that matter to patients. Proposed examples: 1) Instead of measuring prostate cancer survival, Measure the associated comorbidities of incontinence or sexual function. 2) Instead of measuring breast cancer survival, Measure patient satisfaction with breast conserving treatment. THE REBUTTAL: What are the implications of publicizing data that reflects patient-valued outcomes? An alternative therapy with preferable morbidity but increased mortality may seem favorable to patients who do not understand the greater consequences of their decisions. Patients often look for guidance from their physicians on these issues, despite the less favorable outcome from appropriate treatment. Making healthcare decisions on inaccurate data is dangerous.

3 Move to Bundled Payments for Care Cycles THE PROPOSAL: Providers must be made to share the costs of inappropriate services and cost overruns. THE REBUTTAL: 1) Even the best physicians and hospitals cannot control outcomes. Poor outcomes inevitably occur and generate additional cost. Will doctors begin selecting their patients? 2) Bundling payments assumes that all patients with a particular diagnosis or treatment are the same and can be lumped together under a single title. However, patients have individual differences that must be accounted for. 3) Most high-cost scenarios occur in hospitals, where physicians are salaried and do not benefit from ordering high volume of services. 4) Rather, the high costs of healthcare are often derived from: a. The fear of malpractice. b. Patient requests for certainty in diagnostic dilemmas. c. Efforts to practice gold standard medicine wherein therapy is often prescribed without consideration of cost.

4 Integrate Care Delivery Systems THE PROPOSAL: Reduce the degree of overlap or redundancy among health care providers and facilities in the same geographic region. Large facilities might focus on high-technology advanced procedures while discontinuing routine procedures. Concentrate volume in fewer locations. Choose the right location for each service. THE REBUTTAL: 1) This solution may be successful in a single-payer healthcare system. However, as long as hospitals and healthcare systems are competing one another, this proposal will fail. 2) Competition plays an important role in motivating providers to enhance value. 3) Competition plays a crucial role in cost control. With a single provider in a geographic region, what prevents them from raising costs without competition? 4) Concentrating volume limits patient access to healthcare.

5 Expand Geographic Reach THE PROPOSAL: Geographic expansion with a hub and spoke model of superior providers such as MD Anderson or Children s Hospital of Philadelphia or Cleveland Clinic. Each IPU will have satellite facilities with rotating clinicians. THE REBUTTAL: 1) Defining these superior providers will be controversial. 2) Creating and maintaining additional satellite facilities will be at the expense of the institution. It is more cost-effective for an institution to consolidate resources. 3) Large academic centers often have no economic incentive to expand geographic reach. Many patients travel to these institutions on their own accord to gain 2 nd or 3 rd opinions and to obtain subspecialized care.

6 Build an Enabling Information Technology Platform THE PROPOSAL: Develop an IT platform that is: - patient centered - uses common data definitions - encompasses all types of data - includes expert systems for every medical condition - easy to extract information - unified among multiple hospitals and health systems THE REBUTTAL: 1) Creating this ideal IT platform is challenging. 2) Competition among IT companies is the driving force for the development of new problem-solving applications. 3) Access to information is valuable, but it is no substitute for the patient-physician relationship.

Conclusion It is imperative that radiologists review, analyze, and voice their assessments on healthcare reform. Silence to healthcare proposals suggests disinterested agreement. Active discussion regarding changes in healthcare policy should be encouraged.

Thank You Please email with questions: gita@iupui.edu Indianapolis, IN