GENERAL SCIENTIFIC SESSION 2 (HONORED GUEST LECTURE) GENERAL SCIENTIFIC SESSION 2 (HONORED GUEST LECTURE)
Volume, Value and Turbochargers: Bridging the Chasm Between Volume and Value-Based Health Care Edward C. Benzel, MD Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio Correspondence: Edward C. Benzel, MD, Chair, Department of Neurosurgery, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, S40, Cleveland, OH 44195. E-mail: [email protected] Copyright © 2015 by the Congress of Neurological Surgeons.
T
his article addresses the bridging of the chasm between volume and value-based health care. Some of the material presented herein is opinion (the author’s), but most of the material represents facts, cold hard facts. We begin with a definition of chasm: “A deep fissure in the earth, rock or another surface synonymous with gorge or abyss.” A chasm may also be thought of as “a profound difference between people and/or viewpoints.” Such is often the case when the discussion involves healthcare economics. Over the past several decades, we have resided on a plateau of volume-based medical care. However, we are approaching a chasm and its adjacent abyss. Across this chasm there exists another plateau on which value-based medical care resides (Figure 1A). We will likely arrive there in 5 to 10 years. It is clearly a question of balance as to whether we can bridge this chasm between these plateaus (Figure 1B). If we cannot, we will fall into the abyss. In this abyss loom unsustainable quality health care and the collapse of the existing healthcare system. Marcus Welby, MD, was perhaps the most influential television medical drama of the late 1960s to early 1970, a remote (relatively) time during which value-based medical care prevailed. In this show, Robert Young played Dr Marcus Welby. He was portrayed as a kind, compassionate, and caring physician (Figure 2). He was all things to all people. He was honest, empathetic, and caring. He lived by the golden rule and acted accordingly. He placed an emphasis on value.
VALUE
The 2014 CNS Annual Meeting presentation on which this article is based is available at http://bit.ly/1Na2LK7.
CLINICAL NEUROSURGERY
The use of goods and resources should correspond to the value of said goods and resources. However, as we emerged from the value-based care medical system of Marcus Welby times to today, the use of healthcare goods and services has diverged from value. We have transitioned from a value-based healthcare system of the Marcus
Welby era to the volume-based care system of today. In the volume-based healthcare system of today, we physicians are rewarded for the volume of care provided; ie, the more we do, the more we are paid. We have emerged from a system in which we were rewarded for the good we did to a system in which we are rewarded for what and how much we do. In 2008, Michael Wefers and I addressed the inversion of the foundation of the medical financial structure.1 In this article, we spoke of the traditional lynchpin of medicine in which doctors will do what is right for their patients while avoiding excess cost and without consideration of personal or financial gain, aka the American Medical Association Code of Ethics.2 In other words, there was a strong emphasis on value (value = quality/cost). The American Medical Association code of ethics states, “[W]hile physicians should be conscious of cost and not provide or prescribe unnecessary services, concern for the quality of care the patient receives should be the physician’s first consideration.”2 We emphasized this point by stating, “a physician’s due consideration of cost is in fact critical to the maintenance of a system that desires to use social resources in the most economically efficient manner.”1 In the good old days, doctors had little concern for reimbursement, insurers functioned as financiers, and industry stayed in the background. Then doctors, insurers, and industry began to focus increasingly on reimbursement. Hence, volume-based medicine emerged, along with practice managers, reimbursement specialists, device and pharmaceutical manufacturer advocates, consultants, specialty hospitals, political advocates, and political action committees. The existing financial structure was not designed for, and simply could not withstand, this onslaught of self-interests. We went from a pyramidal structure in which Marcus Welby and his colleagues took care of the masses to an inverted pyramidal structure in which the masses financially take care of physicians (Figure 3A and 3B).
VOLUME 62 | NUMBER 1 | AUGUST 2015 | 73
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BENZEL
FIGURE 1. The chasm between volume-based and value-based care (A). Bridging the chasm via a tightrope (B).
This disconnect between the use of goods and resources from value of services provided occurred fundamentally as a result of the gaming of the system by all players involved (ie, physicians, insurers, industry). While use approximated value in the good old days, today, the use of goods and resources has increased, and the value of our product (medical goods and services) has decreased. We now have a situation in which we have transformed from a system in which we were rewarded for the good we did to one that rewards us for how much we do. FIGURE 3. The pyramid of the financial structure of health care during the prior era of value-based medicine (A). Over the past several decades, the pyramid has become inverted as we have evolved into a volume-based healthcare system (B).
THE SUSTAINABILITY OF QUALITY HEALTH CARE
FIGURE 2. Marcus Welby, MD.
74 | VOLUME 62 | NUMBER 1 | AUGUST 2015
So I ask the question, “Is quality health care for the masses sustainable?” To answer this question, we must look in the mirror. Healthcare costs are indeed spinning out of control. In 1960, the percentage of the gross domestic product consumed by health care was 5.1%. Today, it approaches 20% (Figure 4). This trend cannot continue. We in the United States spend $7000 per capita on health care annually. Considering that the US population is roughly 300 million people, the annual expenditure for health care in the United States is well over $2 trillion. US healthcare annual spending is more than $2000 greater per capita than the next closest spender, which is Norway. US healthcare spending is,
www.neurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
VOLUME VS VALUE IN HEALTH CARE
Vested Interests There have been many publications on the subject of vested interests in medicine, dating back over a decade.3 It is well known that articles addressing the value of a medical product (such as a drug or device) that are written by physicians who have vested interest with the product statistically show a more positive effect of the product than articles written by those who do not have a vested interest. Such bias threatens the integrity of the peerreviewed literature, on which our decision-making process is based. FIGURE 4. Healthcare percentage of gross national product (GDP). Note a steady increase over the previous 5 decades.
in fact, .2-fold greater than that of many first-world and European countries such as Austria, Canada, Denmark, Finland, and Germany, all of which have, at the very least, health care that is equivalent in quality to that received in the United States (Figure 5). We described 6 points that must be addressed if indeed quality health care is to be sustainable1: 1. The vested self-interests of multiple parties involved with either the clinical decision-making process or the healthcare policy decision-making process; 2. The unbalanced and uncontrolled influence of some stakeholders over others (absence of a check and balance); 3. The notion among Americans that they are entitled to expensive services of often unproven quality; 4. The notion that the rationing of health care does not exist or should not be allowed to exist; 5. The marginalization of the physician as a decision maker; and 6. The resultant loss of allure to the practice of medicine, with a diminution of the quality and availability of young physicians. Each is addressed separately.
Unbalanced and Uncontrolled Influence All surgeons are influenced in one way or another by how much they do. There clearly exists an unbalanced and uncontrolled influence of hospitals over physicians, payers over physicians, payers over hospitals, and industry perhaps over all players. Such a milieu fosters escalation of cost, with a minimal impact on quality (value = quality/cost). Hence, value declines in such an environment. Entitlement of Americans to Expensive Services Many Americans feel entitled to expensive services. The best care is often equated with the most expensive care, and this is simply not true in many cases. Such entitlement falls on the backdrop of a flawed reimbursement system in which the cost of care is affected by the decision maker (ie, physician, who does not pay), the consumer (who does not make the decisions or encourages expensive decisions) and the hospital (which plays a passive role). The drug and device industry then acts accordingly and to its own advantage. Rationing In another article, we discussed rationing and asked the question, Does an ethical basis for rationing exist?4 Can a patient stratification
FIGURE 5. Per-capita healthcare spending. Note that the US spending ($7000 per capita) is markedly greater than that of all other first-world countries.
CLINICAL NEUROSURGERY
VOLUME 62 | NUMBER 1 | AUGUST 2015 | 75
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
BENZEL
process be devised to determine those with greatest need or for whom the value of treatment is greatest? Let us drill down on this by first defining rationing. Rationing may be defined as the controlled distribution of resources, goods, or services. In the United States, we have a free-market system, or rather a free-market system in transition. This is essentially “what-amarket-will-bear economy.” Canada has and enforces a single universal healthcare plan. I ask the question, “Does rationing of health care exist in Canada and/or the United States?” One does not need to look too far to realize that transplantation surgery, with waiting lists and prioritizations of the people on the lists, is one of many vivid examples of rationing that permeate our healthcare environment. Let us drill down on rationing a bit further by analyzing a ratio, the financial contribution to the healthcare pool over the value of goods and services received (financial contribution to the healthcare pool/value of goods and services received). A net contributor’s ratio is .1. A net recipient’s ratio is ,1. If all of us across the country have a ratio of 1, there is no rationing. However, such is not so. Hence, net contributors and net recipients coexist. In this latter scenario, rationing also exists. Rationing exists when a subset of the population receives more expensive elements of care and another subset does not. Such rationing occurs in the United States, in which a free-market system in transition is at play. However, what if a subset of the population (ie, net contributors) forgo, perhaps unknowingly, more expensive elements of care to enable the availability of less expensive care to another subset (ie, net recipients)? Such occurs in the Canadian universal healthcare system. In a purely universal system, higher-end goods and services are withheld from net contributors in exchange for the provision of goods and services to net recipients. In a purely free-market system (ie, United States), higher-end goods and services are provided to net contributors, thus forsaking further contributions that might have been provided to net recipients. Looking at this another way, in a purely free-market system, higher-end goods and services are withheld from net recipients in exchange for the provision of goods and services to net contributors. Rationing is often considered to be a dirty word. Regardless, it is prevalent. Governmental and political downplay swirls around the notion of rationing. It often becomes an emotional pawn for political advantage. Terms such as withholding of care and death panels are often used to confuse those who consider rationing a viable strategy for the distribution of goods and services. I suggest that we embrace rationing and levels of quality care (ie, a modified universal healthcare system). More on this will appear in the pages that follow.
and our services are gradually becoming commoditized. Commoditization is defined as “the act of making a product, good, or service easy to obtain by making it as uniform, plentiful, and affordable as possible.” Do we really want to be thought of as being uniform, plentiful, and affordable? I think not.
The Marginalization of the Physician as a Decision Maker Physicians, in general, are seeing a decline in respect as we are marginalized as decision makers. We are increasingly using algorithms and care paths. Shift work is becoming commonplace,
So, we stand on the edge of a plateau, looking into a chasm. How do we get to the other side while avoiding plummeting into the deep and dark abyss that separates volume-based healthcare from value-based care? Can we bridge this gap? I have several further suggestions: straddle 2 boats, perform value-based
76 | VOLUME 62 | NUMBER 1 | AUGUST 2015
Loss of Allure to the Practice of Medicine The loss of the allure of medicine, in particular neurosurgery, as an evident eventuality goes without saying. This has not happened to date but will transpire if the current trend continues.
WHAT TO DO? Do I have ideas? Sure, all of us have ideas. I will share some of mine with you. Canada has a universal healthcare system with no access to private care. The United Kingdom has a similar plan but allows individuals to seek care outside of the universal healthcare system. The allowance of care outside the universal healthcare system offloads the system by diverting some of the cost of health care to the private sector and away from the public patient care pool. This frees up more resources for the public system (universal healthcare system). This helps absorb the financial burden of the universal healthcare system. The free-market system in the United States, on the other hand, is unique. In this system, all patients are cared for in a private sector, of sorts. An Alternative System I suggest an alternative system in which a universal healthcare system with access to private care is established. In this system, the private care is taxed to help subsidize the universal healthcare system. This helps absorb the financial burden and increases resources available for care in the public sector. I liken this to the fundamental functional characteristics of a turbocharger. Hence, I call such a system a turbocharged universal healthcare plan (Figure 6). With a turbocharger, the exhaust from the engine powers a turbine, which in turn compresses air and causes it to fan the fire of the engine, thus increasing its power and energy. Similarly, a healthcare plan in which the taxation is used to energize and fuel patient care and to increase resources for public care could be considered a turbocharged universal healthcare system. Those purchasing better, best, most expensive care subsidize those who cannot afford such care. Those in the public sector still receive great care. This entire process can and should be transparent to all.
BRIDGING THE GAP
www.neurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
VOLUME VS VALUE IN HEALTH CARE
“covered lives,” aka the old health maintenance organization and now the new accountable care organization system types, with a gradual transition from a volume-based to a value-based practice.
FIGURE 6. The analogy of a turbocharger as it pertains to a new modified healthcare system (turbocharged universal health care). See text for details.
research, establish the accurate diagnosis and act accordingly, and provide the right care. Straddle 2 Boats Consider 2 boats, side by side. If we were to put a foot in each of 2 canoes (Figure 7), we would have placed ourselves in a precarious, but perhaps transitional, position. Let us consider the canoe on the left to be a volume-based healthcare canoe and the canoe on the right a value-based healthcare canoe. Somehow, we want to gradually shift our weight from the volume-based healthcare canoe to the value-based care canoe before the 2 canoes diverge so much that we cannot stand in both. In this way, we could bridge the chasm via a transitional diversification of provision of healthcare strategies. Diversification is a means of maintaining a foot in each boat for an extended period of time. Most of us take care of patients on some form of a fee-for-service basis. However, w, may want to place a foot in another boat by looking for ways to manage
Methodologically Sound Value-Based Research A methodologically sound value-based research initiative such as exemplified by comparative effectiveness research can help us understand what to do and to whom. We are, in fact, transitioning into this research arena in neurosurgery today. A word of caution, however, is in order. With comparative effectiveness research, we should not focus on validating what we do. The lawmakers and others can see right through this. We should rather focus on determining the truth. The use of conclusion-based research, in other words, trying to prove that what we do (conclusion) is valid, is laden with bias. We must eliminate bias and again use process-based research to seek the truth. And if we are honest, we will make the greatest strides forward. The converse is perhaps exemplified by the Desmond Disraeli and Mark Twain reference to research in general. “There are three kinds of lies; lies, damned lies, and statistics” (variably attributed to Desmond Disraeli and Mark Twain). It is emphasized that bias can significantly pervert results and the conclusions derived. We must do what is right. Establish an Accurate Diagnosis and Act Accordingly: The Chronic Pain Syndrome We must establish an accurate diagnosis. The chronic pain arena is an example of an environment in which erroneous and flawed decisions are often made. Chronic pain is an entity that we very seldom identify, and the chronic pain syndrome is a diagnosis that we should frequently make but do not. Annually, $635 billion are spent on chronic pain (one-fourth to one-third of overall healthcare expenditures), most of which is spent in vain. If we could eliminate some of this waste, we could decrease the overall cost of medicine. If we can identify the patient with chronic pain syndrome, we might treat the patient more effectively with less waste. In addition, we should carefully consider the wisdom of performing surgery in this group of patients because surgical results in this patient population are abysmal. End-of-Life Care We spend $200 billion, nearly 10% of our healthcare dollars, in the last month or two of life. Surely we can do better than that. Surely we can focus on quality rather than length of life and hence spend money more wisely.
CONCLUSION
FIGURE 7. Two boats, side by side. Straddling both boats can facilitate diversification. See text for details.
CLINICAL NEUROSURGERY
While we ponder strategies to bridge the chasm that separates volume-based from value-based health care, we indeed must perform a balancing act. Can we actually get to the other side without falling into the abyss? We must shrug the market pressures that we face and focus on doing what is right. If we can effectively
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BENZEL
shrug such pressures, we will indeed bridge the chasm. I close with a quote from Machiavelli. He addressed the stresses faced in years gone by, as well as those we face today: “There is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new order of things.” Disclosure The author has no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
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REFERENCES 1. Wefers MH, Benzel EC. Curbing the escalating cost of medical care. SpineLine. 2008;12-18. 2. AMA Code of Ethics, Section 2.09. Available at: http://www.ama-assn. org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page. 3. Choudhry NK, Stelfox HT, Detsky AS. Relationships between authors of clinical practice guidelines and the pharmaceutical industry. JAMA. 2002;287(5): 612-617. 4. Benzel EC, Wefers BA, Eskay-Auerbach M. New technology: efficacy, costeffectiveness and affordability. SpineLine. 2005;8-12.
www.neurosurgery-online.com
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Volume, Value and Turbochargers: Bridging the Chasm Between Volume and Value-Based Health Care Edward C. Benzel, MD Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio Correspondence: Edward C. Benzel, MD, Chair, Department of Neurosurgery, Neurological Institute, Cleveland Clinic, 9500 Euclid Ave, S40, Cleveland, OH 44195. E-mail: [email protected] Copyright © 2015 by the Congress of Neurological Surgeons.
T
his article addresses the bridging of the chasm between volume and value-based health care. Some of the material presented herein is opinion (the author’s), but most of the material represents facts, cold hard facts. We begin with a definition of chasm: “A deep fissure in the earth, rock or another surface synonymous with gorge or abyss.” A chasm may also be thought of as “a profound difference between people and/or viewpoints.” Such is often the case when the discussion involves healthcare economics. Over the past several decades, we have resided on a plateau of volume-based medical care. However, we are approaching a chasm and its adjacent abyss. Across this chasm there exists another plateau on which value-based medical care resides (Figure 1A). We will likely arrive there in 5 to 10 years. It is clearly a question of balance as to whether we can bridge this chasm between these plateaus (Figure 1B). If we cannot, we will fall into the abyss. In this abyss loom unsustainable quality health care and the collapse of the existing healthcare system. Marcus Welby, MD, was perhaps the most influential television medical drama of the late 1960s to early 1970, a remote (relatively) time during which value-based medical care prevailed. In this show, Robert Young played Dr Marcus Welby. He was portrayed as a kind, compassionate, and caring physician (Figure 2). He was all things to all people. He was honest, empathetic, and caring. He lived by the golden rule and acted accordingly. He placed an emphasis on value.
VALUE
The 2014 CNS Annual Meeting presentation on which this article is based is available at http://bit.ly/1Na2LK7.
CLINICAL NEUROSURGERY
The use of goods and resources should correspond to the value of said goods and resources. However, as we emerged from the value-based care medical system of Marcus Welby times to today, the use of healthcare goods and services has diverged from value. We have transitioned from a value-based healthcare system of the Marcus
Welby era to the volume-based care system of today. In the volume-based healthcare system of today, we physicians are rewarded for the volume of care provided; ie, the more we do, the more we are paid. We have emerged from a system in which we were rewarded for the good we did to a system in which we are rewarded for what and how much we do. In 2008, Michael Wefers and I addressed the inversion of the foundation of the medical financial structure.1 In this article, we spoke of the traditional lynchpin of medicine in which doctors will do what is right for their patients while avoiding excess cost and without consideration of personal or financial gain, aka the American Medical Association Code of Ethics.2 In other words, there was a strong emphasis on value (value = quality/cost). The American Medical Association code of ethics states, “[W]hile physicians should be conscious of cost and not provide or prescribe unnecessary services, concern for the quality of care the patient receives should be the physician’s first consideration.”2 We emphasized this point by stating, “a physician’s due consideration of cost is in fact critical to the maintenance of a system that desires to use social resources in the most economically efficient manner.”1 In the good old days, doctors had little concern for reimbursement, insurers functioned as financiers, and industry stayed in the background. Then doctors, insurers, and industry began to focus increasingly on reimbursement. Hence, volume-based medicine emerged, along with practice managers, reimbursement specialists, device and pharmaceutical manufacturer advocates, consultants, specialty hospitals, political advocates, and political action committees. The existing financial structure was not designed for, and simply could not withstand, this onslaught of self-interests. We went from a pyramidal structure in which Marcus Welby and his colleagues took care of the masses to an inverted pyramidal structure in which the masses financially take care of physicians (Figure 3A and 3B).
VOLUME 62 | NUMBER 1 | AUGUST 2015 | 73
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
BENZEL
FIGURE 1. The chasm between volume-based and value-based care (A). Bridging the chasm via a tightrope (B).
This disconnect between the use of goods and resources from value of services provided occurred fundamentally as a result of the gaming of the system by all players involved (ie, physicians, insurers, industry). While use approximated value in the good old days, today, the use of goods and resources has increased, and the value of our product (medical goods and services) has decreased. We now have a situation in which we have transformed from a system in which we were rewarded for the good we did to one that rewards us for how much we do. FIGURE 3. The pyramid of the financial structure of health care during the prior era of value-based medicine (A). Over the past several decades, the pyramid has become inverted as we have evolved into a volume-based healthcare system (B).
THE SUSTAINABILITY OF QUALITY HEALTH CARE
FIGURE 2. Marcus Welby, MD.
74 | VOLUME 62 | NUMBER 1 | AUGUST 2015
So I ask the question, “Is quality health care for the masses sustainable?” To answer this question, we must look in the mirror. Healthcare costs are indeed spinning out of control. In 1960, the percentage of the gross domestic product consumed by health care was 5.1%. Today, it approaches 20% (Figure 4). This trend cannot continue. We in the United States spend $7000 per capita on health care annually. Considering that the US population is roughly 300 million people, the annual expenditure for health care in the United States is well over $2 trillion. US healthcare annual spending is more than $2000 greater per capita than the next closest spender, which is Norway. US healthcare spending is,
www.neurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
VOLUME VS VALUE IN HEALTH CARE
Vested Interests There have been many publications on the subject of vested interests in medicine, dating back over a decade.3 It is well known that articles addressing the value of a medical product (such as a drug or device) that are written by physicians who have vested interest with the product statistically show a more positive effect of the product than articles written by those who do not have a vested interest. Such bias threatens the integrity of the peerreviewed literature, on which our decision-making process is based. FIGURE 4. Healthcare percentage of gross national product (GDP). Note a steady increase over the previous 5 decades.
in fact, .2-fold greater than that of many first-world and European countries such as Austria, Canada, Denmark, Finland, and Germany, all of which have, at the very least, health care that is equivalent in quality to that received in the United States (Figure 5). We described 6 points that must be addressed if indeed quality health care is to be sustainable1: 1. The vested self-interests of multiple parties involved with either the clinical decision-making process or the healthcare policy decision-making process; 2. The unbalanced and uncontrolled influence of some stakeholders over others (absence of a check and balance); 3. The notion among Americans that they are entitled to expensive services of often unproven quality; 4. The notion that the rationing of health care does not exist or should not be allowed to exist; 5. The marginalization of the physician as a decision maker; and 6. The resultant loss of allure to the practice of medicine, with a diminution of the quality and availability of young physicians. Each is addressed separately.
Unbalanced and Uncontrolled Influence All surgeons are influenced in one way or another by how much they do. There clearly exists an unbalanced and uncontrolled influence of hospitals over physicians, payers over physicians, payers over hospitals, and industry perhaps over all players. Such a milieu fosters escalation of cost, with a minimal impact on quality (value = quality/cost). Hence, value declines in such an environment. Entitlement of Americans to Expensive Services Many Americans feel entitled to expensive services. The best care is often equated with the most expensive care, and this is simply not true in many cases. Such entitlement falls on the backdrop of a flawed reimbursement system in which the cost of care is affected by the decision maker (ie, physician, who does not pay), the consumer (who does not make the decisions or encourages expensive decisions) and the hospital (which plays a passive role). The drug and device industry then acts accordingly and to its own advantage. Rationing In another article, we discussed rationing and asked the question, Does an ethical basis for rationing exist?4 Can a patient stratification
FIGURE 5. Per-capita healthcare spending. Note that the US spending ($7000 per capita) is markedly greater than that of all other first-world countries.
CLINICAL NEUROSURGERY
VOLUME 62 | NUMBER 1 | AUGUST 2015 | 75
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
BENZEL
process be devised to determine those with greatest need or for whom the value of treatment is greatest? Let us drill down on this by first defining rationing. Rationing may be defined as the controlled distribution of resources, goods, or services. In the United States, we have a free-market system, or rather a free-market system in transition. This is essentially “what-amarket-will-bear economy.” Canada has and enforces a single universal healthcare plan. I ask the question, “Does rationing of health care exist in Canada and/or the United States?” One does not need to look too far to realize that transplantation surgery, with waiting lists and prioritizations of the people on the lists, is one of many vivid examples of rationing that permeate our healthcare environment. Let us drill down on rationing a bit further by analyzing a ratio, the financial contribution to the healthcare pool over the value of goods and services received (financial contribution to the healthcare pool/value of goods and services received). A net contributor’s ratio is .1. A net recipient’s ratio is ,1. If all of us across the country have a ratio of 1, there is no rationing. However, such is not so. Hence, net contributors and net recipients coexist. In this latter scenario, rationing also exists. Rationing exists when a subset of the population receives more expensive elements of care and another subset does not. Such rationing occurs in the United States, in which a free-market system in transition is at play. However, what if a subset of the population (ie, net contributors) forgo, perhaps unknowingly, more expensive elements of care to enable the availability of less expensive care to another subset (ie, net recipients)? Such occurs in the Canadian universal healthcare system. In a purely universal system, higher-end goods and services are withheld from net contributors in exchange for the provision of goods and services to net recipients. In a purely free-market system (ie, United States), higher-end goods and services are provided to net contributors, thus forsaking further contributions that might have been provided to net recipients. Looking at this another way, in a purely free-market system, higher-end goods and services are withheld from net recipients in exchange for the provision of goods and services to net contributors. Rationing is often considered to be a dirty word. Regardless, it is prevalent. Governmental and political downplay swirls around the notion of rationing. It often becomes an emotional pawn for political advantage. Terms such as withholding of care and death panels are often used to confuse those who consider rationing a viable strategy for the distribution of goods and services. I suggest that we embrace rationing and levels of quality care (ie, a modified universal healthcare system). More on this will appear in the pages that follow.
and our services are gradually becoming commoditized. Commoditization is defined as “the act of making a product, good, or service easy to obtain by making it as uniform, plentiful, and affordable as possible.” Do we really want to be thought of as being uniform, plentiful, and affordable? I think not.
The Marginalization of the Physician as a Decision Maker Physicians, in general, are seeing a decline in respect as we are marginalized as decision makers. We are increasingly using algorithms and care paths. Shift work is becoming commonplace,
So, we stand on the edge of a plateau, looking into a chasm. How do we get to the other side while avoiding plummeting into the deep and dark abyss that separates volume-based healthcare from value-based care? Can we bridge this gap? I have several further suggestions: straddle 2 boats, perform value-based
76 | VOLUME 62 | NUMBER 1 | AUGUST 2015
Loss of Allure to the Practice of Medicine The loss of the allure of medicine, in particular neurosurgery, as an evident eventuality goes without saying. This has not happened to date but will transpire if the current trend continues.
WHAT TO DO? Do I have ideas? Sure, all of us have ideas. I will share some of mine with you. Canada has a universal healthcare system with no access to private care. The United Kingdom has a similar plan but allows individuals to seek care outside of the universal healthcare system. The allowance of care outside the universal healthcare system offloads the system by diverting some of the cost of health care to the private sector and away from the public patient care pool. This frees up more resources for the public system (universal healthcare system). This helps absorb the financial burden of the universal healthcare system. The free-market system in the United States, on the other hand, is unique. In this system, all patients are cared for in a private sector, of sorts. An Alternative System I suggest an alternative system in which a universal healthcare system with access to private care is established. In this system, the private care is taxed to help subsidize the universal healthcare system. This helps absorb the financial burden and increases resources available for care in the public sector. I liken this to the fundamental functional characteristics of a turbocharger. Hence, I call such a system a turbocharged universal healthcare plan (Figure 6). With a turbocharger, the exhaust from the engine powers a turbine, which in turn compresses air and causes it to fan the fire of the engine, thus increasing its power and energy. Similarly, a healthcare plan in which the taxation is used to energize and fuel patient care and to increase resources for public care could be considered a turbocharged universal healthcare system. Those purchasing better, best, most expensive care subsidize those who cannot afford such care. Those in the public sector still receive great care. This entire process can and should be transparent to all.
BRIDGING THE GAP
www.neurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
VOLUME VS VALUE IN HEALTH CARE
“covered lives,” aka the old health maintenance organization and now the new accountable care organization system types, with a gradual transition from a volume-based to a value-based practice.
FIGURE 6. The analogy of a turbocharger as it pertains to a new modified healthcare system (turbocharged universal health care). See text for details.
research, establish the accurate diagnosis and act accordingly, and provide the right care. Straddle 2 Boats Consider 2 boats, side by side. If we were to put a foot in each of 2 canoes (Figure 7), we would have placed ourselves in a precarious, but perhaps transitional, position. Let us consider the canoe on the left to be a volume-based healthcare canoe and the canoe on the right a value-based healthcare canoe. Somehow, we want to gradually shift our weight from the volume-based healthcare canoe to the value-based care canoe before the 2 canoes diverge so much that we cannot stand in both. In this way, we could bridge the chasm via a transitional diversification of provision of healthcare strategies. Diversification is a means of maintaining a foot in each boat for an extended period of time. Most of us take care of patients on some form of a fee-for-service basis. However, w, may want to place a foot in another boat by looking for ways to manage
Methodologically Sound Value-Based Research A methodologically sound value-based research initiative such as exemplified by comparative effectiveness research can help us understand what to do and to whom. We are, in fact, transitioning into this research arena in neurosurgery today. A word of caution, however, is in order. With comparative effectiveness research, we should not focus on validating what we do. The lawmakers and others can see right through this. We should rather focus on determining the truth. The use of conclusion-based research, in other words, trying to prove that what we do (conclusion) is valid, is laden with bias. We must eliminate bias and again use process-based research to seek the truth. And if we are honest, we will make the greatest strides forward. The converse is perhaps exemplified by the Desmond Disraeli and Mark Twain reference to research in general. “There are three kinds of lies; lies, damned lies, and statistics” (variably attributed to Desmond Disraeli and Mark Twain). It is emphasized that bias can significantly pervert results and the conclusions derived. We must do what is right. Establish an Accurate Diagnosis and Act Accordingly: The Chronic Pain Syndrome We must establish an accurate diagnosis. The chronic pain arena is an example of an environment in which erroneous and flawed decisions are often made. Chronic pain is an entity that we very seldom identify, and the chronic pain syndrome is a diagnosis that we should frequently make but do not. Annually, $635 billion are spent on chronic pain (one-fourth to one-third of overall healthcare expenditures), most of which is spent in vain. If we could eliminate some of this waste, we could decrease the overall cost of medicine. If we can identify the patient with chronic pain syndrome, we might treat the patient more effectively with less waste. In addition, we should carefully consider the wisdom of performing surgery in this group of patients because surgical results in this patient population are abysmal. End-of-Life Care We spend $200 billion, nearly 10% of our healthcare dollars, in the last month or two of life. Surely we can do better than that. Surely we can focus on quality rather than length of life and hence spend money more wisely.
CONCLUSION
FIGURE 7. Two boats, side by side. Straddling both boats can facilitate diversification. See text for details.
CLINICAL NEUROSURGERY
While we ponder strategies to bridge the chasm that separates volume-based from value-based health care, we indeed must perform a balancing act. Can we actually get to the other side without falling into the abyss? We must shrug the market pressures that we face and focus on doing what is right. If we can effectively
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BENZEL
shrug such pressures, we will indeed bridge the chasm. I close with a quote from Machiavelli. He addressed the stresses faced in years gone by, as well as those we face today: “There is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new order of things.” Disclosure The author has no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
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REFERENCES 1. Wefers MH, Benzel EC. Curbing the escalating cost of medical care. SpineLine. 2008;12-18. 2. AMA Code of Ethics, Section 2.09. Available at: http://www.ama-assn. org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page. 3. Choudhry NK, Stelfox HT, Detsky AS. Relationships between authors of clinical practice guidelines and the pharmaceutical industry. JAMA. 2002;287(5): 612-617. 4. Benzel EC, Wefers BA, Eskay-Auerbach M. New technology: efficacy, costeffectiveness and affordability. SpineLine. 2005;8-12.
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