Viewpoint Opinion
Invited Commentary
Improving Value Is Improving Health Care, Not Rationing Thomas H. Lee, MD
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 effiViewpoint page 845 cient. 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 to do 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 and efficiency. Indeed, it is a framework for groups of health care personnel to focus on the needs of patients with the same intensity as the noble individual physician that Goitein singles out for praise. Twenty years ago, as capitation was coming to Massachusetts, where I work, I frequently engaged in earnest discussions of the concerns that Goitein raises. Those concerns are still worth worrying about, but the experience of the past 2 decades 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 efficiency have generated more essays and journal articles than actual financial savings. Despite all of the energy and emotion that has gone into implementation of such contracts, the actual cost reductions have been modest or negligible—very low single-digit percentages (eg,
Invited Commentary
Improving Value Is Improving Health Care, Not Rationing Thomas H. Lee, MD
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 effiViewpoint page 845 cient. 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 to do 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 and efficiency. Indeed, it is a framework for groups of health care personnel to focus on the needs of patients with the same intensity as the noble individual physician that Goitein singles out for praise. Twenty years ago, as capitation was coming to Massachusetts, where I work, I frequently engaged in earnest discussions of the concerns that Goitein raises. Those concerns are still worth worrying about, but the experience of the past 2 decades 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 efficiency have generated more essays and journal articles than actual financial savings. Despite all of the energy and emotion that has gone into implementation of such contracts, the actual cost reductions have been modest or negligible—very low single-digit percentages (eg,
