Robert J. Laskowski, MBA, M.D.
President and CEO
Christiana Care Health System
“Listening” is the key to creating value in health care
The Patient Centered Outcomes Research Institute (PCORI) established by the Affordable Care Act (ACA) recently published criteria that it will use to fund research to “help people make informed healthcare decisions.” To this end, PCORI asserts that health care outcomes research should be guided “by the voice of the patient”. This “patient-centric” orientation is key to assuring that comparative effectiveness research truly serves the public. At a fundamental level, all of us who design, deliver and finance health care need to continually remind ourselves that it is the public who we serve first and foremost. The first step in such service is simply to listen.
Whether or not the ACA survives the upcoming Supreme Court decision and/or the presidential election, it will have helped to focus the country’s attention on health care, its cost, its structure and its value to us as individuals. And, regardless of the ACA, the overwhelming issue of health care’s cost and its value to society will remain.
On the issue of patient care, what the individual “feels” appears to matter at least as much as the facts. We who lead health care must understand these feelings as well as the facts, if we are to improve quality and safety and reduce cost. The concept of “value” for the public includes their fears, their biases and the interpretation of their personal experiences much more than any external notion of value as “quality divided by cost."
We have seen the result of misguided attempts to control costs in the 1990s. The letters “HMO” became synonymous with bureaucracy and the denial of care. People were told that they “did not need” care; they were never asked what care they themselves thought they needed. "Gatekeepers," incentivized to reduce operational costs, guarded access to services that people not only wanted but felt they needed. Companies, as the payers of employee sponsored health insurance, were considered the true customers of managed care insurers, not the employees. The results were impressive: health care costs transiently declined until the HMO system quickly imploded under the pressure of public outrage.
In retrospect, most of the administrative decisions made in the '90s HMO era were very reasonable -- when viewed from the professional perspective of medical indications and resource utilization. What was unrecognized was the fundamentally important role of the individual in determining what was “valuable” for them and their family. This oversight proved fatal to the sustainability of the HMO approach.
Choice is a key value of American society. A “gatekeeper” system implies that personal choice will either be denied or constrained. The current controversy over insurance “mandates”, while quite different in substance, bumps into “choice” in a different but similarly unpopular way. The lack of recognition of the great importance that most individuals place on “choice” has distorted the public’s overall view of the ACA. The “sustainability” of the entire approach to health care embodied in the ACA, the vast majority of which is quite good in my opinion, has been consequently thrown into doubt. The message is clear for all those who want to change health care: understand what the public values.
The concept of value must be seen as more inclusive, more nuanced and fundamentally “patient-centered”. Value is making a measureable difference in people’s lives through what we as medical professionals do, in ways that people appreciate and that our society can afford.
Value embodies quality, safety, cost, accessibility, affordability and efficiency. But it is much more than that. From a practical standpoint, patients’ perceptions largely define value. For anything in health care to be valuable to a patient, what matters is what he or she believes, not what we as health professionals think. “Value” functions practically as a verb with the individual as the subject and health care as the object. When we miss this fundamental point, we as health professionals will quickly get out of step with those we are privileged to serve.
This patient-centered formulation of value leads to some very practical conclusions. There is no real way to understand what a person values other than to ask them. While there are many ways to do this, and many caveats (prominently including the fact that people often change their mind depending on the particulars of circumstance), “listening” will always be a key first step in understanding what patients’ value.
By listening, we learn of people’s fears, their hopes, their understanding and their misperceptions. We can teach, guide and comfort rather than simply prescribe and treat. And the health care systems that we design, based on listening to the public, will be much more likely to serve effectively and in a way that lasts.