Value-based healthcare is gaining popularity as an approach to increase sustainability in healthcare. It has its critics, possibly because its roots are in a health system where part of the drive for a hospital to improve outcomes is to increase market share by being the best at what you do. This is not really a solution for improving population health and does not translate well to publicly-funded healthcare systems such as the NHS. However, when we put aside dogma about how we would wish to fund healthcare, value-based healthcare provides us with a very useful set of tools with which to tackle some of the fundamental problems of sustainability in delivering high quality care.
What is value?
Defined by Professor Michael Porter at Harvard Business School, value is defined as a function of outcomes and costs. Therefore to achieve high value we must deliver the best possible outcomes in the most efficient way, outcomes which matter from the perspective of the individual receiving healthcare and not provider process measures or targets. Sir Muir Gray expands on the idea of technical value (outcomes/costs) to specifically describe ‘personal value’ and ‘allocative value’, encouraging us to focus also on shared decision making, individual preferences for care and ensuring that resources are allocated for maximum value. This article seeks to demonstrate that the role of data and informatics in supporting value-based care goes much further than the collection and remote analysis of big datasets – in fact, the true benefit sits much closer to the interaction between clinician and patient.
A recent report from the Commonwealth Fund places the US last amongst developing nations in healthcare. For self-loathing Americans, Christmas couldn’t have come earlier. Raptures of ecstasy were oozing from pores of self-satisfying righteous indignation.
Anyway that, and the shakiness of the metrics for another time.
For now I will focus on one of the conclusions. In analyzing the Britain’s high score on the management of chronic conditions the authors attributed this care coordination to the widespread adoption of health information technology.
That’s like someone saying Chinese food is tasty because chopsticks are widely used.
Sigh! Like quants so fastidious about decimal points they’ve missed the overall point.
Where do I begin?
I’ll start with Mesozoic era, i.e. before health IT was thrust upon Britain’s general practitioners (GPs). Then you had GPs and specialists. In Britain GPs are not optional ornaments for the mantelpiece that you pick up from Ikea when you feel like.
No, they are rather compulsory. Everyone needs to be registered with a GP. Ok, you don’t get fined if you don’t have one, but if you want a referral to a cardiologist you need to see your GP which means you must have one to see in the first place.
Read my lips: no GP, no cardiologist.
If your cardiologist thinks there is nothing wrong with your heart and your problems are supratentorial for which you need to see a shrink, then he must write a letter to your GP asking that he might consider referring you to the psychiatrist. The specialist can’t send you directly to another specialist, bypassing your GP.
It was spring. My medical school class, two years along in our five-and-a-half year endeavor, had earned the “medicinae kandidat” degree. We were now worthy of leaving the basic sciences and research center on the outskirts of town and starting our preparatory clinical, “propedeutic” semester at the University Hospital. In Sweden, at that time, we used a lot of Latin words and phrases. Crohn’s disease was Morbus Crohn, chart notes listed physical exam findings by Latin names for the bodily organs: Cor for the heart, Pulm(ones) for the lungs, Hepar for the liver, etc.
Uppsala Academic Hospital was an imposing campus, with several tall, white towers, housing the most modern wards, laboratories and operating theaters. We were relegated to a pink stucco building that housed the old tuberculosis clinic.
The physical exam course was taught by a couple of older pulmonologists. At first they struck many of us as relics from a bygone era, but as the course went on, our respect grew. These unassuming physicians could percuss a patient’s chest wall and describe in detail what the x-ray would look like, they made us feel the tip of the spleen by turning the patient on his right side, they measured jugular venous pulsations and pedal pulses.
Sometimes we had real patients with remarkably abnormal findings to examine, but we often were charged with examining each other for assessment of normal physical exam findings.
My partner for the Lymphatic System module was Sven Björk, a slow-talking kid from the very north of Sweden. He had jet black, completely straight hair and a broad face with eyes set wide apart. He was part Same, the native, reindeer-herding nomadic population from north of the Arctic Circle.
I visited Safdarjung Hospital in New Delhi today – an institution with 1,531 beds and 145% occupancy rate. Yes, 145%. You do the math. A lot of bed sharing and asking families to bring in cots. It’s right across the street from the All India Institute of Medical Sciences (AIIMS), the premier public healthcare institution in India. While both AIIMS and Safdarjung are run by the federal government, only AIIMS is renowned for famous specialists, world class facilities, and an international reputation to boot. Safdarjung doesn’t suffer such burdens – its specialists are not well known, facilities are dilapidated, and you probably have never heard of it.
I spent several hours walking around, talking to lots of physicians, visiting ICUs and cath labs. I visited the outpatient department where 7,000 people show up every day, many lining up the night before, to get a ticket by 11 a.m., when registration closes and those who haven’t gotten a ticket are out of luck. In the ER, there was a line of between 50 and 100 people waiting to get rabies shots. This is the hospital where every poor person in Delhi unfortunate enough to get a dog bite is sent. They have the rabies serum. Most other public hospitals do not.
Safdarjung has “efficiency” baked in. In a typical year, they do 800 cardiac surgeries, 2,000 angioplasties, 3,000 echocardiograms, and 100,000 EKGs. They see tens of thousands of patients in the cardiology clinic. They have 4 (yes, four) full-time cardiologists on staff. The rest of the work is done by medical residents, who call when they get into trouble. Brigham and Women’s Hospital, which probably doesn’t have one quarter the volume of this place, has 140 cardiologists. The patients at Safdarjung pay essentially nothing. Even their medications are free. For those who are not extremely poor (and I doubt there are many non-poor patients who go to Safdarjung), you do have to pay for your own devices. Need a stent? Bare metal ones cost $200 to $1000. Drug eluting stents are $1500 to $2500. You get to decide which one you want. They have a chart with pictures and prices that looks a lot like a dinner menu. Continue reading…
On June 26, 2012, China’s first wholly foreign-owned private hospital opened its doors to patients in Shanghai. We are hopeful that this is the start of a broader trend of increasing private participation as China upgrades its healthcare services sector.
Anybody who has spent any significant time in a public Chinese hospital knows that there are few greater unmet needs in China than those existing in the healthcare services sector. China’s public hospitals are overcrowded and there are few alternatives, even for those willing to pay a premium for higher-quality care, shorter waiting times, and more personalized service.
Private investors – foreign and Chinese—have been eyeing China’s private healthcare services industry since the Chinese government began experimenting with limited private participation in 1989.
Progress since then has been slow. As of 2012, a dozen years after the start of the healthcare reforms, around 95% of all hospital beds in China are still in public hospitals, and there are only a dozen or so Sino-Foreign hospital joint ventures (mainly providing outpatient services to holders of private insurances and a very small segment of affluent Chinese nationals in first-tier cities like Shanghai, Beijing and Guangzhou).
Will the next ten years see more significant developments? This depends to a large extent on the Chinese government’s willingness to allow foreign participation in the sector.
In 1986, British Prime Minister Margaret Thatcher’s special cabinet committee on AIDS made a fundamentally important decision which changed the course of the emerging HIV epidemic in the UK. In spite of some vocal opposition, it decided there should be clean needle exchanges for injecting drug users (IDUs) to prevent the spread of HIV.
The opposition to that move has been echoed in the years that followed — not least in the United States. Government-financed needle exchanges would condone crime, the critics claimed. It would encourage drug use and give entirely the wrong message to the public.
The experience of the last quarter of century has disproved those fears. There is no question that needle exchanges and drug substitution have reduced HIV: only 2% of new infections in Britain now come through that route. The policy has neither encouraged drug taking nor crime. Similar reports come from other nations that have adopted this approach. Tragically, not all nations have followed such a lead. Nearly half of the countries with epidemics concentrated among IDUs have no needle and syringe programs at all according to UNAIDS. The result is the further spread of HIV and an increasing death toll — only four of every 100 people who inject and are eligible for treatment get antiretroviral (ARV) drugs.
In 2003, 168 countries signed the world’s first public health treaty: the Framework Convention on Tobacco Control (FCTC). The FCTC legally bound countries to enforce major tobacco control measures, ranging from tobacco taxes to regulations on public smoking. Through a massive international effort, the FCTC has assisted countries to improve their tobacco prevention programs, and the treaty continues to be a basis for many new programs that are implementing evidence-based tobacco control strategies.
In an article in PLoS Medicine, we publish new data showing that the food and beverage industry’s activities in low- and middle-income countries parallel that of the tobacco industry in years past; moreover, as cardiovascular disease and diabetes rates rise in poor nations, junk food, soda, and alcohol are statistically the major factors giving rise to deaths among working-age populations, and the newest evidence suggests that educational programs alone aren’t effective when markets are drowned by imports of cheap, unhealthy food and readily-accessible booze. So should the public health community push for a nutritional treaty or governance structure that parallels the successful introduction of the FCTC, but addresses “unhealthy commodities” like junk food? If so, what would such a structure look like?
Zooming out from the debates about soda taxes and similar public health controversies that pit individual freedom against public health desires to reduce disease rates, there are really a few core public health problems now facing global food systems: (1) that undernutrition and famine persist as over-nutrition (malnutrition in the direction of obesity) has appeared in the same poor households in many countries; and (2) that climate change has forced us to think about how to produce food for the world’s 9+ billion people in a manner that is environmentally sound (as highlighted in our recent discussion of Oxfam’s GROW campaign).
Not since the earliest days of Deng Xiaoping’s reforms of the iron rice bowl in the 1980s has China faced as great a need for change as the leaders currently face.
Then as now, the government in Beijing recognized a pressing need to reform the means by which social services were provided. But unlike then, today’s reforms must occur in the midst of a society that has already experienced significant economic growth and has already gone through a painful opening of formerly public services to private competition.
For most Chinese, while their economic futures have materially improved since Deng’s painful reforms were enacted, their access to healthcare has actually deteriorated, a point Yanzhong Huang, the Senior Fellow for Global Health at the Council of Foreign Relations, has made eloquently in his recent research.
Beijing’s struggle to reform its healthcare system brings political concerns, social issues and business pressures together on a collision course. While the need for government and industry to collaborate on these matters is obvious, whether China’s pressing concerns in this area will allow it to do so remains to be seen.
The ever-present temptation in China, to simply resort to government-mandated policies absent industry’s guidance, is one the country has already given into at a national level relative to clean technology, and at a provincial level through the Anhui pharmaceutical pricing model.
You could go on and on like this. But you know what?
No matter how good or bad your system is, there are certain universal truths.
Here are four of them that might make you look at global health care a little differently.
First, health care is getting more expensive, all over the world. A new study by the global consultant, Towers Watson (disclosure: Towers Watson is a Best Doctors client) found that the average medical cost trend around the world will be 10.5% in 2011. In the advanced economies costs will rise by an average of 9.3%. While Americans tend to think of rising medical costs as a uniquely American problem (they’ll rise by 9.9% here), it’s just not true. Canadian costs will rise by 13.3%. In the UK and Switzerland, they will increase by 9.5%, and in France by 8.4%.
Last week in London I met with two of the brightest lights in the UK’s community of physicians looking at Health 2.0. Annabel Bentley is the medical director and head of informatics at Bupa, the UK-based non-profit health insurer, which owns Health Dialog amongst many other activities, and is also a sponsor of the upcoming Health 2.0 Europe conference. Emma Stanton is a psychiatrist, round-the-world yachtswoman, and has just spent two years on assignment working with Sir Liam Donaldson the Chief Medical Officer in the UK, and is on her way to a Harkness fellowship in the US working with Don Berwick & Eliot Fisher. Not bad company!
Both will be speaking at Health 2.0 Europe on April 6–7 in Paris (and you should come too, you can register here!) and both of them gave me some gems about why they think Health 2.0 is important in this brief interview—captured in the glamorous location of the Bupa canteen.