CHICAGO—Since 1980, the medical value gap has widened between the United States and other countries. The U.S. has increased both public and private sector spending, and yet obesity rates are still the highest of any developed country, said Michael S. Benninger, MD, chair of otolaryngology at the Cleveland Clinic in Ohio. “Specialists dominate healthcare delivery in the United States,” he added.
The Affordable Care Act (ACA) was intended to remedy this situation, and it represents an unprecedented health plan consolidation. Its implementation, however, is associated with the escalating cost of healthcare, along with a Centers for Medicare and Medicaid Services (CMS) drive for provider accountability. Both the payer and provider have adopted new technologies, and the past years have seen the rise of both public and private healthcare exchanges and patient cost sharing.
During the Triological Society Annual Meeting, a panel of experts convened to discuss the implications of this evolving landscape for physicians, patients, and optimized care. The panel acknowledged that the new risk-based payment models represent an industry shift that leaves physicians not only to respond to unsustainable costs, but also to absorb the shifting of risks to providers. It is against this backdrop that physicians must look closely at the practice of medicine and define value.
“Value is, basically, quality over cost,” said panel moderator Dr. Benninger, opening the door to the diverse perspectives of the panel members.
“We live in interesting times. … Value is going to be the new buzzword,” said Christine G. Gourin, MD, professor of otolaryngology-head and neck surgery at The Johns Hopkins University School of Medicine in Baltimore. By 2018, 90% of fee-for-service will be reimbursed based on value, she added.
David E. Eibling, MD, professor in the department of otolaryngology at the University of Pittsburgh in Pennsylvania, introduced the role of transparency in value: “The foundation of healthcare, of course, is transparency.” Transparency can be defined as the free, uninhibited flow of information that is open to the scrutiny of others. Dr. Eibling argued that as physicians understand and improve transparency, they will likewise improve overall value. Transparency has the potential not just to fix many of the problems with patient safety, but also to help with healthcare cost and quality. Its many advantages include the fact that it is relatively inexpensive. Transparency also works across all levels of the healthcare system: It improves quality and safety by enhancing the trust among stakeholders in general, and between clinicians and patients in particular. Transparency encourages physicians to put the patients’ interests first to ensure quality care. As such, it is generally welcomed by patients, families, and policy makers.
Moreover, whenever transparency has been introduced as a safety intervention, it has effectively improved performance. For example, the rapid disclosure of adverse events, accompanied by honest explanations and fair and timely settlement offers, has led to improved patient and clinician satisfaction. Unfortunately, transparency is one of the most underused vehicles to improvement in the healthcare system.
The National Patient Safety Foundation’s Leap Institute held a roundtable discussion to determine the role of transparency in the context of patient safety. The resulting report, published in 2015, identified four transparency domains: 1) between clinicians and patients, 2) between clinicians, 3) among organizations, and 4) between organizations and the public. These domains are highly interrelated, and the report recommended that transparency should be emphasized in all of the domains. The report noted, “If transparency were a medication, it would be a blockbuster, with millions of dollars in sales and accolades the world over. While it is crucial to be mindful of the obstacles to transparency and the tensions—and the fact that many stakeholders benefit from our current largely nontransparent system—our review convinces us that a healthcare system that embraces transparency across the four domains will be one that produces safer care, better outcomes, and more trust among all of the involved parties. Notwithstanding the potential rewards, making this happen will depend on powerful, courageous leadership and an underlying culture of safety.”
The report also included many recommendations, some of which were targeted at specific domains and some of which are relevant to all stakeholders. For example, the report recommended that all financial and nonfinancial conflicts of interest be disclosed. Additionally, it suggested that patients be given reliable information in a form that they would find useful. Such information would include data that represent the perspectives and needs of patients and families.
Transparency will be enhanced when organizational cultures emphasize it at all levels and work to share lessons learned and adopt best practices from peer organizations. Emphasis should be placed on accurate communication with patients in particular, and with all stakeholders in general. Dr. Eibling emphasized, specifically, transparency among organizations and the public. He also cautioned, “The business of transparency is strong medicine, and it needs to be dispensed carefully.” Transparency requires competency and an appropriate environment to support its use.
As the need for transparency increases, stakeholders are shifting and redefining themselves. The ACA has facilitated consolidation in the form of hospital mergers and acquisitions. Physicians are being integrated into hospitals, and reimbursement is being transformed from fee-for-service to value-based. On the one hand, consolidation can reduce the amount of competition and cause healthcare costs to soar. On the other hand, the shift toward a population-based health model has tended to lower costs.
There is also recognition that greater care integration across physicians, hospitals, and other healthcare delivery providers can achieve cost savings and provide well-coordinated care. Thus, hospitals are purchasing physician practices in an effort to integrate care, allowing hospitals to provide ambulatory services and receive higher reimbursement from CMS and other payers. These mergers can be attractive to physicians, who may see an opportunity to give up their private practices in exchange for a steady outcome, better work-life balance, lower malpractice insurance costs, and a reduction/elimination of practice issues.
All told, however, there is a “huge jump of cost when you become part of a health system,” said Kathleen L. Yaremchuk, MD, chair of the department of otolaryngology-head and neck surgery at Henry Ford Health System in Detroit. “As much as we talk about clinical
integration in health system acquisitions and mergers, it’s about the dollars.”
Such mergers may also create barriers to access. Earl H. Harley, MD, FACS, FAAP, associate professor in the department of otolaryngology-head and neck surgery, specializing in pediatric otolaryngology, at Georgetown University Medical Center in Washington, D.C., gave voice to the needs of underserved populations. He explained that he grew up in the inner city of Detroit, where patients tend to be sicker and have limited access to healthcare. This limited access meant that many patients obtained care in the emergency room, said Dr. Benninger, noting the “paucity of well-trained primary care physicians.” Dr. Harley explained that he now uses physician assistants so that he can see more patients, increasing patient access to care.
A Growing Understanding of Value
“A lot of these topics are interesting, intriguing, and scary,” said Dr. Benninger. Value will be defined, and doctors can either participate or not participate in the process. In order to contribute the most to the discussion, they likely must expand their understanding of value and quality. Most physicians consider quality to be the actual surgery itself. Patients, however, will likely expand quality to include physician accessibility, surgery, their post-surgery experience, and their physician’s responsiveness to post-surgery problems. Of these, perhaps the most important two criteria are patient perception and accessibility. As Dr. Eibling acknowledged, “The stakeholders that are most critical are patients.”
Lara Pullen is a freelance medical writer based in Illinois.