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Porter/Teisberg JAMA Article: Out-of-the-Box or Out-of-Touch?
“In theory, there is no difference between theory and reality. In reality, there is.” Yogi Bera
Out-of-the-box thinking is good; out-of-touch thinking is not. Dr. Porter and Teisberg’s (PT’s) recent article in JAMA “How Physicians Can Change the Future of Health Care” is disappointing, unrealistic and dangerous.
- Disappointing: Please Answer the Challenges About Why Your Theory isn’t Workable
- Unrealistic: Money Does Matter a Lot
- Dangerous: Measuring Process in Health Care Does Add Value
What’s so seductive about their writing is that about 90% of it makes a great deal of sense; however, the other 10% doesn’t, and this 10% is foundational to their thinking.
1) Disappointing: Please Answer the Challenges About Why Your Theory isn’t Workable
PT’s JAMA article does not address the many challenges made to their theories. PT argue that “A value-based system is grounded in 3 simple principles: (1) the goal is value for patients, (2) care delivery is organized around medical conditions and care cycles, and (3) results are measured.”
There’s nothing new here. These arguments were made in their recent book, Redefining Healthcare.
Nobody disagrees with Principle #1. Porter and Teisberg have received well deserved praise for bringing this issue to the forefront of the national health care debate. However, we all know that Al Gore didn’t invent the Internet and I hope they aren’t taking credit for inventing this idea.
While Principles #2 and #3 are conceptually appealing, they have no grounding in reality. Here is representative commentary from distinguished scholars and economists commenting on their book:
PT vastly underestimate how hard it will be in practice to categorize the complaints patients present to the health system neatly into a finite set of standard “medical conditions” each with a standard life cycle. Next, they vastly underestimate how hard it will be to define, measure, and capture in user-friendly metrics the often subtle, multidimensional “health outcomes” for which the providers of health care are to be rewarded in PT’s utopian market.
The authors’ proposed units of competition are individual medical conditions; patients would be quoted a single price by each competing delivery network for the entire cycle of treatment for any given condition. While this would promote integration of care within each condition, it ignores a very important fact: Patients have a nasty habit of having more than one thing wrong with them. In Medicare, for example, patients with multiple chronic conditions account for a disproportionate share of spending, and patients with three chronic conditions see an average of 13 physicians annually. This creates a huge need for care coordination across conditions, which is why the IOM recently recommended not only that someone be designated to coordinate care for each patient, but that he or she be paid for doing so.
Okay, so no one has asked the obvious question, and so I will ask it myself. If episode-of-care pricing and service-line organization is such a good idea (as declared by Porter/Teisberg and re-declared by yours truly), why don’t we see more of it already? Certainly the real world is full of imperfect information and mis-aligned incentives, but, still…It would seem that scheduled surgeries (e.g., knee/hip replacement), maternity (delivery), and other forms of care where there is an identifiable beginning, middle, and end of the episode would be good candidates (with due accomodation for severity differences, outliers, etc.). Why do the pundits keep pointing to examples from Indianapolis in the 1980s and Oxford Healthcare in the 1990s? Why not something from the here and now? Wassup?
Porter’s lack of specificity about the outcome measures needed to improve the performance of the U.S. health care systems, and his glib reliance on “competition” to institute change, flies in the face of international evidence: Nowhere has any public or private institution managed to curb the excesses of powerful providers more interested in their wallets than demonstrably improving patients’ health.
There are many others who challenge PT’s thinking. For example read the many comments here and here and here.
Doctors P &T, would you please come back to earth and address these issues? Who is going to bell the cat and how? “Just do it” might be OK for round 1 of the debate (your book), but not for round 2.
For the foreseeable future, the lack of workability for Principles #2 and #3 are deal breakers, not just significant implementation challenges.
2) Unrealistic: Money Does Matter a Lot
Porter and Teisberg write: “The only real solution to the national health care problem is to dramatically increase the value of the care delivered for all the money being spent. That will never be achieved from the outside, by tinkering with payment schemes and incentives.”
I found it odd that PT’s JAMA article does not even mention some of the substantive and very real payment reforms being advocated by the physician community, e.g., the medical home model and the repeal of the sustainable growth rate (SGR) methodology. This is like writing an article entitled “Holes of the World” and not mentioning the Grand Canyon.
Let’s consider the medical home model being advocated by 4 primary care physician organizations representing 330,000 physicians. Pocketbook issues have been a motivator to bring physicians together.
Here’s a question for Drs. P & T: Would you consider the medical home model to be a solution that 1) dramatically increases the value of care, or 2) is “tinkering with payment schemes and incentives”?
My answer is “both” and that’s precisely the point. Creating value is important, AND changing payment schemes and incentives is also critical. One without the other won’t work.
I’m reminded of the words of Jim Clark, founder of Netscape, Silicon Graphics, and Healtheon. After leaving Healtheon, Clark was asked if he would ever again start a new company in health care. He replied (I’m paraphrasing here): No. There might be $400 million waste in health care, but that waste is food on someone’s table and they fight and scrap to hold on to it.
3) Dangerous: Measuring Process in Health Care Does Add Value
PT’s JAMA article threatens to undo the significant progress being made on developing and implementing evidence based medicine (EBM) guidelines.
PT suggest that “basing reporting and rewards on process compliance is the wrong way to go. It will lead inevitably to the micromanagement of medical practice. Practice guidelines tend to freeze today’s best practices and retard innovation. Measuring actual results…is a far better alternative.”
Measuring actual results is a great goal for the long-term, but downplaying the value of measuring process compliance in health care borders on professorial malpractice.
I’ll pose back to P&T their own criterion: does reporting on process compliance add value? Let’s consider 3 different situations:
1) For many consumer purchases, reporting process steps will not add value. I just want to know if my new DVD player shows the best picture. I don’t need to understand the 347 process steps that the manufacturer went though to build the device. I’m OK with reading critic and consumer reviews about “results”.
2) For many consumer purchases, reporting process steps does add value. When you go to Jiffy Lube, you get a 17 point checklist on work performed. This checklist is akin to evidence based guidelines for your car. Some consumers will not care about the process, while others will be comforted by knowing that a) evidence based guidelines exist for my car, and b) Jiffy Lube is aware of these evidence based guidelines, and c) Jiffy Lube has documented that they are following the guidelines when servicing my car. Reporting these process steps adds value.
3) For health care, reporting process steps is essential:
a) Measuring “actual results” is not practically achievable. Desirable patient outcomes are not agreed upon nor easily measurable (see the discussion above).
b) The evidence strongly suggests that guidelines are followed only about 55% of the time. Proactive consumers will and should be asking their physicians “Did you follow the guidelines for my condition? if not, why not?” Lives are at stake.
c) Consumers often are co-producers in the process of their own health care. Achieving good results often is dependent upon patient knowledge and patient self-care. Patients need to understand their role in the process. This is particularly true for patients with long-term, chronic conditions.
Dr. Porter, Dr. Teisberg — please come back and engage with those of us living in the read world of health care. Your ideas are definitely out-of-the-box; but let’s get back in-touch. I welcome your comments on this blog.
Vince Kuraitis
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I think Uwe, Gail, Jamie, and Alan have got it right!
I, too, was stimulated by the original PT HBS article, then later digested their full tome (with some dyspepsia), and now find little new or comforting in the JAMA piece. Overall, I find value competition an appealing thesis presented by PT with cogent reasoning but with repetitious belaboring of basic principles and little insight or attention to the many thorny details e.g., how to transition from current system of misaligned stakeholder incentives to future state of value competition as perhaps the most glaring omission. I also feel that primary care and the management of comorbid patients is glossed over in the glorification of specialized IPUs. The authors appear unacquainted with the complex needs of multiply comorbid patients when they reflect a bias that healthcare is rendered for one medical condition at a time, conveniently separated into discrete and independent episodes of care. Anyone with a passing acquaintance to the disease management world knows that just isn’t often the case, particularly for older patients.
Independent, specialized IPUs make a lot of sense in some special circumstances (not all, Professor Herzlinger, just some), but whats to prevent serious conflicts between the condition-specific treatment plans for the comorbid patient with HF, CAD, COPD, and CKD in the absence of a unifying or integrating primary care entity a medical home, indeed? The described segmentation of specialized care might be not only be inconvenient but potentially lethal for these complex patients, as the expertise for treating different conditions simultaneously may be missing or at least diminished in such a system.
Sure, we are all eager for faster EMR adoption, but mere availability of an integrated EMR is insufficient to mitigate this threat. PT conveniently stipulate that primary care would become its own medical condition and would function in primary care IPUs in similar fashion to HF IPUs, ESRD IPUs, etc. But elsewhere they extol the need for expert diagnosis to reside within these specialized condition-specific units, and I foresee serious practical issues with getting undiagnosed patients to the right unit for proper diagnosis unless there is an upstream primary care process that does a lot of preliminary diagnosis or triage and appropriate referral to individual IPUs. Real patients are messy, disorganized, organic beings whose health care needs are very hard to fit into a pristine model of primary care delivery, no matter how glossy its philosophic patina, how articulate the recitation of its basic principles, or how impressive the pedigree of its esteemed architects.
That said, PT’s thesis is not without merit. They are dead on identifying many ways in which the current health care system fails to support value creation. Results focus for defining value for specified medical conditions across span of care is a worthwhile (but hardly novel) suggestion; however, their denigration of process measures as inadequate to the task of value competition, with simultaneous positing of outcomes measures as necessary and sufficient to the task is naive in my view. Most QI experts of the past 2-3 decades who have been working in real organizations with real data and real providers have concluded that there are too few suitable, untainted outcomes measures to do the job of measuring health care at an appropriate level of granularity across the entire spectrum of care a combination of outcomes and process measures are needed to do this job. Even then, this is very hard work to do well, and exceedingly challenging to do at all at the practitioner level.
As always, the devil is in the details, and PT appear to want to stay at the 30,000 foot level where details are moot. To wit:
1. Multiply comorbid patients do not fit their model well, since it seems to assume that discrete medical conditions occur separately and independently; despite the glib assertion that comorbidity management will fall within the expertise of these specialized IPUs, I think that is an unwarranted assumption based on the realities of specialty medicine as we know it today.
2. Primary care IPUs may or may not perform the medical home function that has been recently postulated by others (ACP, AAFP) as the next needed evolution for health care reform. Elsewhere on this blog I have commented on the far greater challenge for primary care to escape extinction in the next decade.
3. The concept of most care rendered by independent, specialized provider units overlooks the fundamentals of primary care from several other perspectives patients preference for having care integration through a single individual or team of clinicians, integration of care for multiple conditions, risk identification and management for multiple conditions, treatment integration across multiple conditions, etc.
4. Prevention is glossed over as a uniform good without a careful distinction between cost-beneficial (i.e., cost saving) programs and cost-effective programs (i.e.,cost that yields adequate return in health outcomes or QALYs)
5. Measuring results over the span of care for medical conditions has conceptual appeal, but may be difficult from practical perspective; if that span is 2-3 years for some conditions, 3-5 for others, how does one decide on the appropriate economic exchanges that should be transacted in the meantime? Care can’t be wholly funded with a balloon payment on the back end of a 3 or 5 year process, so I assume some interim scheme would be needed to approximate the expected outcome, with true-up after the fact. This will become a very difficult negotiation.
6. Gain sharing with providers is encouraged based on value creation as measured by results over span of care for medical conditions; there are many devils in those details that seem reminiscent of zero-sum competition, since total gains less total investments become the fixed pie for dividing among the contributing stakeholders. I am somewhat surprised that PT do not extend the gain sharing concept to include the patients, as well who, more than they, need an incentive to improve adherence to virtuous lifestyle behaviors and adherence to treatment plans?
7. Transparency is also a laudable objective, but despite offering relevant health care quality information to a demanding public for the past decade, I am still uncertain about the degree to which they can understand or use that data. The ESRI Report on Report Cards, issued in 1998, observed that while most consumers say they want report cards, when presented with them, they don’t appear to be willing or able to use them for health care decisions. I trend to agree with the ESRI conclusion: Simply informing consumers (that is, making information available to them) is not the same as informed consumerism, whereby consumers understand and use the information provided to choose health plans and providers and to demand accountability. To foster the latter, employers face technical challenges, educational challenges, and socio-psychological challenges which are daunting. In the 9 years since, have we made much progress in the sophistication of the public in accessing, interpreting, and using quality data?
PT have made a valuable contribution to the extent they are provoking discussion and debate about health care reform, and the many thorny challenges we face with the organization, incentives, transparency, measurement and reporting, provider types and distribution, longitudinal coordination of care, and continuity of health care delivery. Whether their substantive ideas will represent a lasting contribution or not is hard to tell at this point, but they fall short of a complete or practical prescription for what ails health care today. My suspicion is that a far less elegant, and more complex, messy set of pluralistic partial solutions may be the next best step that our society can take in this direction, given political constraints, competing interests, system inertia, and deep public ambivalence. At last report, it is still the case that the average citizen regards U.S. health care as sick, or perhaps even in crisis, but ask about your personal health care and you hear it is viewed as satisfactory, in general – and woe be unto him/her who would render it asunder in the 2008 elections!
I actually purchased this book and read it…with much effort. Too much detail and not enough well linked strategic conclusions.
Bottom-line, it was not well written from an editors viewpoint and the book further complicated an “industy” that is already complicated. I had hoped for some vision in the book….and did not find it….just more confusion, albeit that is the basic problem.
Our healthcare “system” has merely become too complicated to be successful. There is a solution…..but not traditional…and perhaps our international colleagues will be leading the charge in how to better address the pending crisis in chronic disease management. In the US we are “playing with the boxes” and “throwing out the toys.”
I hope this paper trail can help get to a higher level.
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P and T got it right. The process of change in health care can be compared with the age of enlightenment. It is not the authority who says what is right or wrong but the value he is creating. So in a time with lots of distrust and problems in health care systems worldwide we need a debate on values and more transparency about these values (outcomes). Of course there are different point of views between doctors, patients, health insurence companies and politicians. And of course there is a lot of money and many emotions within patient care. But as long as we are doing a professional job we can tell what our goals are and wether we have reached them. Measurement of outcomes and data bases are instruments for leadership and learning and not for control and sanctions. If you can show the value you can discuss about the prizes.
If we doctors don’t do that work, other institutions will do it for us (or against us???).
This episode of change is already happening. We doctors can decide wether we will take over the leadership or we will be victims of this change. Start now, learn, find the right ways of financing, take care of risks and harms. Stop complaining.