Monday, April 11, 2011

Porter on Value in Health Care II

In his most recent NEJM article on value in health care (2010), Michael Porter expands the definition and measurement of this complex and elusive construct.  He considers value as health outcomes relative to costs, or efficiency.  Although he comments on outcomes as condition-specific and multidimensional, he does not adequately define effectiveness of delivered care. As is the case throughout the U.S. health care system,  the model of value is an attempt to associate cycles of health care and the “outcome measures hierarchy” with an estimate of dollar cost  for individual patients.  Certainly time  is a critical dimension in evaluation of health care value, but scaling this dimension to condition-specific cycles of individual care is itself a costly operation in measuring value.  Furthermore, this approach ignores individuals of the  population in sustainable good health due to effective preventive health care strategies or other social welfare policies. The individual patient should not be considered in isolation from the relevant population.  Rather data on patient outcomes related to value should be aggregated to reflect not only cycles of care for particular conditions of disease or ill-health, but also the presence of sustainable good health.

Porter advocates a market-based vision of health care and deplores the lack of competition among providers based on actual results, but appears very careful to recognize the threat posed by public access to data describing such provider performance. Instead of patient choice of provider based on performance data,  he emphasizes evidence based provider innovation and improvement through analysis of their own performance.    Health care services markets in the U.S. are substantially weakened by the lack of patient access to provider performance data as well as a professional culture highly protective of provider privacy with respect to such data.  Evidence based patient choice in health care services markets would significantly enhance value provided.

Health information systems for such data in the U.S. are primarily designed to support billing processes in the pervasive fee-for-service business model. This is the underlying motivation for ever more detailed and multidimensional data collection on the care of individual patients. Relentless focus on the individual renders more difficult the measurement of teamwork contributions to patient care. Thus one of the most important value-creating organizational reforms tends to be obscured in the complexity of rigorous attribution of shared clinical services and reponsibilities to individual care. It should also be emphasized that the use of billing codes for compilation of clinical conditions and treatments results in an unresolved bias in the quality of such data.

Porter's “value equation” does not consider the administrative component of the care cycle,apparently under the assumption that these costs remain invariant across medical conditions. Institutional arrangements designed to improve delivery of value in health care include Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Accountable Care Organizations (ACOs), and Patient Centered Medical Homes (PCMHs). They require varying administrative arrangements to incentivize and transact payment schemes for improvement of service quality to specific populations. These arrangements may increase the administrative component of health care costs as well as the complexity of the integrated system. Although difficult to estimate, such costs must be taken into account in the “value equation,” especially in the U.S. health care context.

I mentioned in an earlier commentary on Porter's value framework that the exclusive focus on financial dimensions of care obscures the more elusive ideological, cultural and ethical assumptions underlying the U.S. health care system. In particular, the value framework assumes that individual patients have a sustainable relationship with their care providers, which is obviously not the case. Even if it were feasible to calculate value in the “equation” suggested by Porter, the model would not be applicable in a context where there is such a high rate of patient mobility among providers as well as in and out of various insurance arrangements over relatively short time horizons. The relationship between the patient and his or her providers is probably the most important dimension of value in health care – encompassing values of access, trust, sustainability and continuity. The U.S. corporate health insurance business has designed this relationship out of the system – and thus destroyed the very foundation of health care value-creation.

[1] Bohmer RMJ, Lee TH. The Shifting Mission of Health Care Delivery Organizations. N.Engl.J.Med. 2009 August 6;361(6):551-553.
[2] Lee TH. Putting the Value Framework to Work. N.Engl.J.Med. 2010 12/23;363(26):2481-2483.
[3] Porter M. What is Strategy? Harvard Business Review 1996 November/December;74(6):61-78.
[4] Porter ME. A Strategy for Health Care Reform -- Toward a Value-Based System. N.Engl.J.Med. 2009 July 9;361(2):109-112.
[5] Porter ME. What Is Value in Health Care? N.Engl.J.Med. 2010;363(26):2477-2481.
[6] Porter ME, Teisberg EO. How Physicians Can Change the Future of Health Care. JAMA 2007 March 14;297(10):1103-1111.