Establishing Value in Hepatology Care

Amidst discussions on liver care, transplants, and infections was a session on Value-Based Medicine in Hepatology, on the third day at The Liver Meeting 2014, an annual event by the American Association for the Study of Liver Disease, held in Boston, Massachusetts, from November 7 to 11, 2014. Presenters saw a huge turnout for the session, a sign of increased interest in value-based care.

During the first presentation, “Value-based medicine, redefining healthcare,” Elizabeth Teisberg, PhD, MEng, MS, professor, The Dartmouth Center for Health Care Delivery Science, The Dartmouth Institute, and author of Redefining Health Care: Creating Value-Based Competition on Results brought forth her expertise in transforming care for those suffering from chronic health conditions. She began her presentation by talking about the mindset of volume to value, and emphasized the need to spell healthcare differently: health care not healthcare. “It has become essential that we recognize them as separate entities that are equally important,” said Dr Teisberg. We need to understand that patients and families desire health, not treatment alone, she said.

According to Dr. Teisberg, cost containment is not the only goal of healthcare; the goal is also improved health. “Traditionally, competition among healthcare providers did not create value for patients. Tactics such as increased revenue, restricted services, increased bargaining power, capturing patients, and limited choices are all examples of bad competition.” Per Dr Teisberg, the current definition of competition needs to increase value for patients to create a win-win situation for them.

Value = Health outcomes

Cost of delivering outcomes

Value can be increased by improving outcomes and reducing costs. She cited an example of an accurate diagnosis of a patient’s condition the first time around. This, she said, can reduce future erroneous treatments while reducing wasteful costs.

“In healthcare, value is created at the level of the individual patient.” According to Dr Teisberg, we can organize to deliver solutions for patients with similar needs, such as a care plan or a care path that can be customized per patient. This could deliver an effective, efficient, and integrated health care, she said.

Citing an example of an integrated practice unit in Germany for migraines that she visited, she found that the efficient use of an integrated delivery team reduced pain, increased days of work, lowered overall costs of care, while bundled payment aligned medical and financial success for the organization. “But being patient-centric needs measurement of meaningful outcomes,” she said, which needs measuring specifically catered outcomes. She emphasized the need for an honest empathy for patients, “Ask about things that matter in healthcare and things that have positive outcomes during the care experience, such as ‘has your pain reduced’ or ‘did we respect your choices’ etc.”

The subsequent talk was by John I. Allen, MD, MBA, professor of medicine and clinical chief of digestive diseases, Yale School of Medicine, and president-elect of the American Gastroenterological Association, whose research interests include quality improvement, performance metrics, and cost-effectiveness of medical care. During his talk entitled, “Health outcome: measuring what matters,” he agreed with what Dr Teisberg said. His hope is that by the year 2020, universal coverage may be the truth and healthcare will move on to be a retail service. He talked about categorizing patient into 5 types based on their health plans: Medicaid, Medicare, marketplace, employer-paid, and self-paid.

Dr Allen continued with the history of how process measures were developed in the United States, modeled on the process measures by the Japanese company Toyota. Now it’s more about outcomes measures, he said, a change initiated by the book coauthored by Dr Teisberg.

Today’s value equation he said has changed. While the denominator is constant, patient outcomes of importance have replaced the existing numerator of quality and efficacy parameters.

According to Dr Allen, integrated delivery networks will bring about a radical change in healthcare, and he believes they are a good step forward. Care models for chronic disease, he said, needs the development of a chronic care model to restructure care programs. He went on to discuss how the Yale Liver Program was developed with his initiative and that of several other hepatologists; the aim of this program is the seamless transition of a patient from inpatient to outpatient care, with outcomes defined for each team of providers.

Dr Allen quoted from a review article by Michael Porter and Thomas Lee, in the October 2013 Harvard Business Review, The Strategy That Will Fix Health Care: "Providers that cling to today’s broken system will become dinosaurs."

“The value equation must be returned to the patient to improve outcomes.”

Thomas H. Lee, MD, chief medical officer of Press Ganey Associates, Inc, took the podium next. Migrating his experience from Partners Healthcare, a not-for-profit, integrated healthcare delivery system, his role at Press Ganey is to help providers identify performance opportunities across the continuum of care. His talk, “Improving value of care in chronic conditions,” started off with healthcare reform. He said that the affordable care act was only phase 1—phases 2 and 3 are underway and are creating turmoil. “Change will happen, but change does not always happen beautifully.” Boards, leadership, and front-line clinicians are stepping back now, to examine what their practices currently do and how they are actually doing it.

Healthcare challenges are the same globally, according to Dr Lee, and the irresistible drivers of change include medical progress, an aging population, and the global economy. This, he said, can result in chaos as there are too many people involved, there is too much to do, and no one has all the information or is fully accountable. This chaos and turmoil can lead to gaps in quality, safety, and outcomes of care. “Every stakeholder in healthcare has a role to play in transformation, but providers must be protagonists.”

A value-based framework to develop a high-value delivery system for functional improvements are all intertwined; you can’t pick and choose. You need a team, data to analyze and improve on, and incentives for improvement; together, they would result in a tangible improvement in outcomes.

“Healthcare is about meeting patient’s needs. Heterogeneity of patients and their needs is a paralyzing force. We need to group patients into segments with similar needs so that teams that care for these patients can do so reliably, effectively, and efficiently,” said Dr Lee. Reiterating Teisberg’s rhetoric, Dr Lee said that outcomes need to be real; not just pain, but anxiety, confusion, and getting home after an episode are real outcomes that matter to patients. They need to be measured. Waiting time in a clinic, ease of access, convenience, practice amenities did not matter to patients he said. Patients are more concerned about being heard by their healthcare provider. Quoting a colleague, Dr Lee said, “Patients actually know what matters.”