“I’m your friend,” Harvard Business School Professor Michael Porter, MBA, PhD, told a sometimes skeptical audience during his keynote address at the ASA’s annual meeting, ANESTHESIOLOGY 2016. “I’m trying to help you see a better way forward, and avoid the bad outcomes that may happen if we don’t transform healthcare.”
Porter is a well-known economist, an expert on business strategy, and the author of the book Redefining Health Care: Creating Value-Based Competition on Results. In his speech to the ASA, he argued the case for redefining health care by making “value for the patient” the unifying purpose, and he urged anesthesiologists to forget pay for volume.
“How should anesthesiologists engage in bundled payments?” Porter asked. “Jump on them!”
Explaining that he has spent the past 15 years immersed in studying health care delivery, Porter said that he looks on health care as one of the world’s “most fundamental and intractable problems.” He asked listeners to think again about anesthesiology practice, and its role and responsibilities in the future of health care.
“We’ve got to get over some history here,” Porter said, and abandon a strategy which up to now has been chiefly defensive. “Our most important role is to be part of the care team for a condition.” He believes that the medical condition is the proper unit of value creation and value measurement in health care delivery.
“If we’re not improving value, we’re failing. It doesn’t matter how smart or well-trained we are, or how hard we’re working,” he said. “Value is created in caring for a patient’s medical condition over the full care cycle. It’s the set of outcomes that matter for the condition, divided by the total costs of delivering these outcomes over the full cycle of care.”
“Stop protecting our traditional roles”
“You can’t think about anesthesiology as a discrete service,” Porter said. “We can’t think of ourselves as specialists. We’ve got to stop protecting our traditional roles and get ahead of this.” Porter advised anesthesiologists to think about expanding our role in value creation outside the traditional operating room, including pain management outside of surgery, and hospice/palliative care.
Paralleling the often-quoted and widely disliked language of the Institute of Medicine’s 2010 report, “The Future of Nursing”, Porter advised the audience to “use physicians and skilled staff at the top of their licenses.” That statement prompted ASA President-elect Jeff Plagenhoef, MD, to comment later, “I heard that line from the Institute of Medicine, and I thought ‘But he was doing so well!’”
Porter advised anesthesiologists to change our frame of reference. “We can’t think about our specific silo. Value is created around conditions, not around specialties or procedures or locations. Departments, service lines – none of these make sense for value.” His belief is that the structure of healthcare systems must evolve toward integrated practice units and high-volume centers of excellence organized around specific conditions – “the right care in the right location.”
“You guys have been a specialty silo, and you’ve got to change,” Porter declared. “In too many health systems I’ve been involved with, the anesthesiologists didn’t want to play. They wanted to keep their departments separate from the institutes of the centers.” This is an unwise strategy, he said. “The future is going to be what you’re avoiding.”
Today’s poor measurement of cost and quality
Efforts to reduce cost don’t work, Porter said, because we haven’t accurately measured it. “Medicine has been a fact-free zone,” he said. “Cost must be measured by patient and condition, with costs aggregated over the full cycle of care. This requires mapping the care process. We need to look at actual expense, not the sum of charges billing or collected.”
Porter believes that incremental solutions for improving a specific piece of the healthcare system have limited impact. “Incremental improvement doesn’t change the trajectory of the system. We can’t continue laying more requirements on the fundamental structure,” he said.
Porter’s key points about quality and outcome measurement are already familiar to ASA and CSA members who have taken part in Perioperative Surgical Home initiatives. Much of quality measurement today is flawed because it focuses on processes and indicators rather than on outcomes.
“We’re going to be measuring a lot of stuff, but not the stuff we’re measuring now. Forgive me, but a lot of that really is not important,” he said.
Porter recommends using three major categories of outcome measurement after illness or operation:
The health status achieved or retained;
The process of recovery, defined as the time to recovery and return to normal function, and the barriers to recovery including pain, complications, and adverse effects;
The sustainability of health, including recurrences, long-term consequences of treatment, and long-term clinical and functional status.
“We want patients to tell us how they’re doing,” Porter said. “Outcomes are always multi-dimensional, and should include what matters most to patients, not just to clinicians. We need a standard set of outcomes for each condition that everyone is using.”
Our professional societies, including the ASA, Porter believes, should lead the emphasis on conditions as the foundation for transforming healthcare, and should help with insight and research. They should also promote bundled payment “as a way to preserve our incomes and to get credit for what we do,” he said. “We’ve got to get on the bus for bundles!”
“I don’t want to be overly simplistic,” Porter said, “but we can’t defend the roles we’ve had in the past. It’s not good for patients, not good for the system, and not good for us.”