CHICAGO — Anesthesiologists who resist the move toward value-based healthcare risk becoming dinosaurs, according to a prominent economist who is widely viewed as the architect of the value model.
"This is the future," said Michael Porter, Bishop William Lawrence University Professor at Harvard Business School and director of the Institute for Strategy and Competitiveness in Boston. Value-based models may still be more of the exception than the norm, but they are here to stay, said Porter.
"We have to stop protecting our traditional roles and get ahead of this — do the things that we can do the best and do the things that stretch us," Porter said during his keynote speech to an audience of several thousand here at Anesthesiology 2016 from the American Society of Anesthesiologists (ASA).
Otherwise, "my fear is that you all will become commodity players," he said.
The audience listened raptly, but did not react with enthusiasm as Porter outlined a system centered around patients and conditions, with teams of highly specialized clinicians.
Porter was chosen for his ability to stimulate discussion, said Daniel Cole, MD, professor of clinical anesthesiology at the University of California, Los Angeles David Geffen School of Medicine, who is president of the ASA.
"I asked him to speak to give us his contemporary ideas and to be thought-provoking," Dr Cole told Medscape Medical News. "We live in a volatile age in healthcare," he added.
"My perception is that anesthesiologists have been struggling to preserve their roles," Porter explained. "The general orientation in this field has been to be defensive."
But he said he believes better times are ahead for those who can move forward.
"I think we're entering a period where it's going to be really exciting, much more interesting, and much more satisfying to be an anesthesiologist," Porter said.
The Value Proposition
The healthcare field has been fiercely resistant to innovation, and cost-cutting solutions have largely failed — in part because no one knows the true underlying costs, Porter pointed out. The field has also been unsuccessful because it has lacked clarity about goals, he added.
The goal and purpose "must be value for the patient," said Porter. He defines that as the actual outcomes (that matter to the patient) being delivered, and gauges how good those outcomes are, relative to the total cost of delivery.
If the outcomes are delivered and improve over time, or at lower costs, "we are succeeding," Porter explained. "If we're not improving value, we are failing."
Anesthesiologists should embrace value-based reimbursement. If they don't, they are "going to be just suffering pressure on fees" and be stuck with lower reimbursement, he said. But being a part of the value proposition could actually increase income.
To do this, though, means changing the way anesthesiologists practice, he said. Healthcare has been focused on interventions, or specific specialties, or sites of care, but this does not work for the value proposition. "You can't just think about the anesthesiologists, it also matters what everybody else does that's involved in the care of the patient," he said. Continue Reading Continue Reading Value is about the process, the entire care cycle for a patient's condition — whether breast cancer or heart disease or another condition — not particular silos. "This is an epic change in perspective," said Porter.
Porter laid out the six steps he said are necessary to transform healthcare into a value-driven field.
First, providers must reorganize the delivery of care so that it is centered around a condition. Porter has advised several organizations on how to establish what he calls integrated practice units (IPUs). One of those — the M.D. Anderson Cancer Center in Houston — has set up such a unit for head and neck cancer, he reported.
Patients see a dedicated team of clinicians, most in the same facility. The IPU has a pathologist who only reads head and neck tumor specimens and a radiologist who only interprets head and neck tumor images.
Not every healthcare organization can be so specialized, Porter noted, but M.D. Anderson "has the volume to afford to do this, and do it well."
Still, anesthesiologists need to see themselves on the breast cancer team or the cardiac surgery team. "You're not on the anesthesiology team anymore," he pointed out.
And clinicians need to hyperspecialize, because studies have shown that experience and volume improve quality and value. "We still have too many clinicians today who revel in the variety of things we do," he said.
Measuring value is also crucial. "Healthcare is the only place in my entire career I've seen that is a fact-free zone," said Porter. Value has been impossible to determine because costs are not transparent and outcomes have not been systematically measured.
When outcomes have been measured, they are the wrong ones. "Processes and indicators are not outcomes," said Porter. The most important quality measure is the outcome that's important to the patient — are they in pain or suffering in some way, how long do they stay healthy, and what are the consequences of the therapy. "The patients know a lot better how they're doing than we do, except for clinical indicators," he noted.
The reimbursement system also has to change — from volume to value — and health organizations have to be transformed into systems of care. Systems should not think of themselves solely as local providers because that results in too much duplication of care. And health needs a better information-technology platform, said Porter.
Stop Protecting Turf
Porter chided anesthesiologists for expending too much energy on turf battles instead of figuring out how to move ahead.
"In this field, we have a religious debate about nurse anesthetists. You've got to stop that debate," said Porter. There is plenty of work and not enough anesthesiologists, so each could be part of a team. "We're dinosaurs if we keep having that debate."
In his work with healthcare organizations, he explained, he encounters anesthesiologists who have no interest in joining an IPU. "That's not a healthy way to think about the future," he noted.
Anesthesiologists can expand their role in the surgical care cycle by taking on duties such as preparing for surgery, conducting preop assessments, minimizing cognitive effects, and helping improve cycling through the operating room, he said. Outside of the hospital, the field can find opportunities in outpatient surgery, coverage in rural areas, radiation therapy, critical care, pain management, hospice, and palliative care, said Porter.
The specialists need to "get on the bus for bundles," he said, and accept a fixed payment for a full cycle of care. Bundled pay rewards those who are efficient and penalizes those who aren't. They are also "physician-centric," he explained; doctors have the flexibility to do things in the most efficient way, and are rewarded directly for good outcomes. With other models, like capitation, the hospital is in the driver's seat and determines how much of the reward to share with physicians.
Dr Cole said he agrees with much of Porter's assessments, although he noted that what Porter laid out is more of a vision than a reality, given that an overnight transformation to what he calls patient-oriented care teams is not possible.
"Anesthesiology has a long and rich heritage of working in teams," Dr Cole said. Teams "need to be physician-led because there are life-and-death decisions made frequently and routinely."
Healthcare "is in a transformative era," Dr Cole told Medscape Medical News. He likens it to the change that occurred when video stores were replaced by online streaming.
It is not clear exactly how the transformation will occur, "but one thing is certain," he said. "it's essentially a fact that healthcare is moving to value-based reimbursement."
Anesthesiology 2016 from the American Society of Anesthesiologists. Presented October 22, 2016.
Dr Cole has disclosed no relevant financial relationships.