Improving Value Is Improving Health Care, Not Rationing
Authors: Thomas H. Lee
Journal: JAMA Internal Medicine (2014)

Hegel’s Triad—thesis, antithesis, synthesis—suggests that when good people disagree, the issue is not which is right, but how to integrate the 2 perspectives. In this issue of JAMA Internal Medicine, Goitein1 raises concerns about the potential dangers of providing physicians with financial incentives to become more efficient. Although I respect her concerns, I also respect concerns articulated by Berwick and Hackbarth2 and others that we are at a point of crisis that demands a dramatic response from physicians and other clinicians. Simply put, health care is consuming too much of society’s resources and failing all too often to meet patients’ needs. A strategic focus on improvement of value is the “synthesis” of these perspectives that provides a path forward for health care providers.3,4 It is not rationing or a constraint on the ability of individual physicians to seek and todo their best for individual patients. It is a framework for clinicians to determine whether they are improving as they try to learn how to work together to meet patients’ needs with increasing effectiveness andefficiency. Indeed, it is a framework for groups ofhealth carepersonnel to focuson theneedsof patientswith the same intensity as thenoble individual physician thatGoitein singles out for praise. Twenty years ago, as capitationwas coming toMassachusetts, where I work, I frequently engaged in earnest discussions of the concerns that Goitein raises. Those concerns are stillworthworrying about, but the experienceof thepast 2decades provides reassurance—and also highlights the need for tactics besides putting pressure for efficiency on individual physicians. First, it is fair to say that capitation and other physician incentives for efficiencyhavegeneratedmoreessays and journal articles than actual financial savings. Despite all of the energy and emotion that has gone into implementation of such contracts, theactual cost reductionshavebeenmodest ornegligible—very low single-digit percentages (eg, <2%) of total costs.5Under suchcontracts, care is sometimesmovedto lower cost settings (eg, from teaching hospital to community facility), but there is no evidence that needed care has beenwithheld. I cannot even find worrisome vignettes. In fact, my years of experience as a physician leader of a large health care delivery system with many large capitated contracts suggests that physicians simply will not withhold care that they believe patients need, even if the costs of that care hurt them financially. They will be upset as they contemplate the fiscal impact of needed care, but they will not withhold it. Financial incentives do matter, of course, and there is little question that fee-for-service payments encourage the performance of care that is of low or no value to patients. But financial incentives to reduce spending have some powerful counter-balancing forces. Physicians deeply care how they are viewed by their patients, their colleagues, and their friends and family. No one wants to be seen as someone who does not deliver adequate care. Thus, incentive systems that pressure individual physicians to be parsimonious do surprisingly little to reduce health care spending, and I just do not see evidence that they have compromised patients’ outcomes. Payments based on incentives do make physicians unhappy, and that unhappiness adds fuel to an already burning fire. Physicians’ lives are changing, and they are losing some of the individual autonomythat theypreviouslyenjoyedas the healthcare systemremodels.Manyphysiciansmourn thedays when their “right” to do whatever they believed was reasonable for the patient before them was unquestioned. But that perspectiveevolved ina simpler era,when lesswasknownand onephysicianactuallymightbeable toknowmostofwhatwas important, when there was less we could do and one physician might be able to do most of it, and when often one physician reallywas all thatwasneeded to givemost patients care at the state-of-the-science. This perspective is, to be blunt, a last-century perspective. It reflects a time when patient outcomes were consideredunmeasurable andwhen the idea of teamcaremeant everyone following the orders of whichever physician was in charge. Today, dozens of clinical personnel interact with patients receivingmedical care for issues of any complexity. Coordination of their efforts does not happen spontaneously, if at all. Coordinationamongseveralhealth careproviders,when it does occur, inevitably influences the relationship between an individual physician and an individual patient. But coordination and standardization of howclinicianswork together leads to better patient care, better outcomes, and sometimes even better efficiency. The value framework that Goitein criticizes is a driver of improvement—a “scoreboard” that can help clinicians see if theyaremoving theneedleon theoutcomes thatmatter topatients, and/or improving theefficiencywithwhichtheyachieve these outcomes. Reducing costs in ways that hurt outcomes is not improving value. Improving outcomes without raising costs is improving value. So is reducing costs without compromisingoutcomes.Surprisinglyoften, it ispossible todoboth at once—improve outcomes and reduce costs—but that rarely happens because of the individual physician working harder or more brilliantly on his or her own. Improving outcomes and reducing costs happens because of changes in the ways clinicians work with each other and with the patient, and standardization of these teamwork approaches. Teamwork is as fundamental to the value framework as the hard work of autonomous individual clinician is to fee-for-service medicine. The fact is that we Viewpoint page 845 Viewpoint Opinion