Thursday, July 9, 2009

A Summary of a Summary of a Book. Dr. Porter's New England Journal Piece on High Value Healthcare Systems

Another ‘Perspective’ piece in the New England Journal of Medicine caught the eye of the Disease Management Care Blog. Written by a father of bundled payments, Michael Porter, it outlines the elements necessary to get to a ‘value-based’ healthcare system.

This time something in the NEJM is actually worth knowing about. What's more, if you take the time to read the article, you won’t have to read Dr. Porter's important, if lengthy, book “Redefining Health Care.” The DMCB thinks this NEJM piece is really one of those executive book summaries that busy captains of industry read in airport lounges. The only downside is that you’ll miss the part in the book where Dr. Porter references an article written by the DMCB and colleagues.

No matter. The expectation-exceeding DMCB is pleased to offer up a two paragraph outline of Dr. Porter’s NEJM health reform outline. No lounge for you: you can dispatch this at your desk with a few bites of lunch and be all the smarter for it. Then you can click on through to your other favorite blogs so you can get back to your job (or - hint - forward the link to your colleagues). After all, it's Friday and it's time to wrap things up. You don't want to be cornered at the end of the day with a pile of unfinished business.....

Commercial health insurers need to compete on the basis of delivering value for their enrollees. Employers who buy that insurance have a stake in their employees’ health. If we can increase the value offered by insurers, we can help keep employers from abandoning their workforce to the individual market or, worse, becoming under or uninsured. Persons without access to employer-based insurance should a) have access to the same deductable tax treatment employers enjoy and b) should be able get the volume discounts and other advantages of joining in large regional pools. We should require everyone to have health insurance and couple that to subsidies for persons that otherwise wouldn’t be able to afford it.

Once everyone has health insurance, Dr. Porter says the next steps are to increase value. Start out by measuring and reporting meaningful consumer-friendly outcomes on every provider, doctor and hospital. Wellness and prevention should be covered, preferably as a bundled package of services. Services should be organized around ‘conditions,’ (e.g., heart attack) not around location (e.g., the hospital) and payments should be bundled in a manner that pays for the condition ‘episode.’ Providers that achieve high quality and low cost for their conditions should be rewarded with more business, but not to the point where they achieve monopolies. The electronic health record will support reform, not drive it. In contrast, enabling patients to be better participants in their own care is a critically important part of health reform. New organizations in D.C. will be necessary to regulate all of this.

(The DMCB has always been partial to the notion of bundled payments, especially because there's a good fit for population-based care management/disease management and dovetails with accountable care organizations. Yet, they stand in distinct contrast to the 'medical home' policy option of having the primary care provider be a leading 'coordinator' of services in exchange for a separate care management fee.

In addition, while Dr. Porter is all about outcomes, the DMCB isn't too sure that insurers can be necessarily blamed for trumping the denominator function of 'value' [defined as 'outcome/price'] because purchasers want the lowest premium possible. Unfortunately, that can mean coverage denials, cherry picking and consumer cost sharing -- and not being enlightened, having open season enrollment and accepting a high medical loss ratio.

The DMCB also doubts the usefulness of measuring performance at the individual provider level, where low numbers of patients with conditions of interest may mathematically result in 'unstable' measures: all it takes is one very high A1c to blow the group average.

Dr. Porter seems to think of insurers as large utilities or intermediaries that package and deliver services, when what they're all about is transferring risk. That's a definitional problem, not a show stopper.

The DMCB really likes Dr. Porter's recognition that patient-consumers need to become active in managing their own conditions. To celebrate, it had seconds on its lunchtime soup


HMS said...

As long as we continue to speak of health care in economic terms, it's unlikely that we will get anywhere.

What exactly is the "value" that the proponents of "high value healthcare systems" refer to? Is it a polite word for "profit"? Based on what i have read so far, that appears to be the case.

Patient care, as you probably remember, is not about economy. Economy is just one of many aspects of health care; poor return is merely the sign & symptom of gross mismanagement.

Jaan Sidorov said...

platensimycin makes an excellent point about the real purpose of medicine: it's called healing. Since that can't be deconstucted into 'units' that are 'priced,' economics are insufficient when it comes to fixing health care. The argument is that good healing is ultimately sustainable. It's like the DMCB's spawn: while the three of them represented a 'cost' with little 'return on investment,' children enriched the DMCB and its spouse's lives in many ways and there was still money in the checking account.

And the DMCB will admit to being seduced by the lure of high falutin health economics. Whether it has any link to reality doesn't make it any less fun to think about.

That being said, in defense of the DMCB and Porter's POV:

Beware the notion that not-for-profits aren't just as mercenary. They call it a surplus, and the DMCB has seen some pretty obscene health system surpluses.