Considering this context, my comments were intended to be viewed strictly from an economic perspective; I believe that the application of business management principles to health care delivery in general, and knowledge management strategies in particular, will have a beneficial effect on our health care system, and that everyone, ( i.e. patient’s, providers, our nation, etc.) will share in these benefits. At the same time I acknowledge that what anyone posts can be appreciated from various perspectives.

Your comments and question invite a variety of responses that I think would come down to one’s philosophy on life. If you have been reading my comments on this and other topics, (biotech threads, etc.) you already know how I will answer your question. I feel that more than anything else, we have lost relationships in medicine and looking at health care delivery from the perspective of rebuilding the relationships we have lost, in the new context of the 21st century delivery system, is a useful mental model.

Although this is overly simplistic, (briefly) in an “idealized” health care system I see patients, health care providers, and the health care organization as “partners” who are working together to create “good health”. In such a system care is indeed patient-centered, efficient, cost-effective, etc. but at the same time members of each group are aware not only of their own needs, but also of the needs of others in their group and the other two groups as well.

Patients, for example, would be educated about health care utilzation issues. They would realize that resources are indeed limited and make responsible informed health care/lifestyle choices etc. They would also learn enough about the complexity, subtlety, and uncertainties that are related to medicine and health care delivery to know the difference between what reasonable and unreasonable expectations are, and to better understand why there are bad outcomes in some clinical circumstances despite the fact that everything that could be done was done and that no mistakes were made.

In return, the doctors and the health care organization (i.e. executive leadership, etc.) would both be patient advocates, seeking the best outcomes with the best treaments available, all other considerations being of secondary importance. Treatment decisions concerning health care resources would be made by physicians, not financial officers and based on evidence. In the absence of clear cut evidence, physician experience would be given due consideration. The administration would work together in partnership with physicians to develop a truly collaborative leadership model of governance.

In such a system, the patient-physician relationship would be strongly supported. The health care would be completely integrated, incorporating preventative care and “risk management” components into acute/episodic care, across the entire continuum of a patient’s life.

So my answer to your question is that we as a society do indeed “own” health care knowledge and that those who are in a position to expand this pool of knowledge should do so in such a way that the benefits to their fellow human beings are maximized.

The health care industry is just now beginning to recognize what other industries have known for well over a decade. Our economy is now a knowledge economy and the key to any organization’s (or any profession’s) success will be the effective management of its collective knowledge or “intellectual capital”.

This above information/subject line forces me to write the following that I have contemplated on for many, many years. The knowledge that makes healthcare possible is largely built on and derived from the failures, deaths and successes of our related family lineage suffering going back over time. The suffering and guinea pig aspects of all our ancestors has paved the way for this knowledge that some profession now controls for some reason. My obvious question then is does that make healthcare knowledge a product of value that we all own indirectly and should all benefit from directly because of where and how it came from??

The health care industry is just now beginning to recognize what other industries have known for well over a decade. Our economy is now a knowledge economy and the key to any organization’s (or any profession’s) success will be the effective management of its collective knowledge or “intellectual capital”.

A Disease Management program, like many other health care enterprises, is fundamentally about knowledge and “connectivity”; the knowledge and expertise of the people involved in delivering the care and the particular manner in which they are connected to patients and to one another.

In the era of the knowledge economy, the highly successful health care organizations will be those that develop an overarching strategy for their knowledge management, such that value to patients, other stakeholders, and the system as a whole, is maximized.

Concerning the relationship between DM and the Integrated Delivery System:

Where does a “disease management” organization end and integrated health care delivery system begin? The answer to this question may be fairly obvious now, but this may not be the case five to ten years from now. The more comprehensive the services offered by a DM enterprise the closer it comes (in theory) to an integrated health care delivery system that has areas of exceptional care.

This may be a good time to bring up the solutions offered by “disease management,” which I define as a system of care that increases quality to manage insurance risk for populations defined by a chronic condition. Assuming for a moment that increases in some quality domains can reduce insurers’ claims expense within a fiscal year (admittedly debatable, but the data suggests it’s true), the DM industry discovered years ago that their chronically ill enrollees had multiple co-morbid conditions and developed tools to address them. They had to: focusing only on a single condition meant not meeting their performance guarantees.

Long gone are the days in which DM “vendors” balkanized health care; they are now grown-up DM “organizations” with an integrated interlocking approach that can coordinate care across multiple co-morbidities. In the case of heart failure, the data has been compelling enough to warrant the AHA/ACC to include DM in their latest guideline for the management of heart failure – the number one cost DRG among Medicare beneficiaries. Look close at any DM organization that manages diabetes, and you’ll find programs that co-manage hypertension, hyperlipidemia, tobacco abuse, obesity and coronary artery disease. You’ll also find a growing alliance with primary care physicians (who need all the help they can get) who, like Gail, think there is a better approach to care than the 13 physicians, 12 of whom get home earlier and have a better take home pay than the “lucky” 13th.

I am still digesting P&T’s book, but it seems to me that the condition “episode” care and financing approach for the chronically ill is already in place and being relied on by the majority of commerical insurers. These are the ones who are already buying longitudinal team-based services based on value.

Physicians as Commodities: (sad but true)

I am a physician. I am a pathologist. I am a Federal (VA) employee. In many respects I am being viewed as a commodity. A component of my salary is even called “market pay”. The unfortunate reality for me is that the people who are determining what I get paid (both at the national and local/regional levels) understand little or nothing about what I do or the value that I actually bring to Veterans, their clinical providers, and to the system as a whole. (Even worse, they don’t care). In fact, the criteria that they are using are almost completely disconnected from my contribution to patient care.

The Clinical Laboratory: (Something I actually know a bit about)

While the health care industry has been striving to develop an “evidence-base” to support the practice of medicine, the evidence that various agencies have been using to determine the value
that pathologists and medical technologists bring to health care has been meager at best and is becoming increasingly irrelevant as we move towards more collaborative models of health care delivery.

As I mentioned in a previous post on another thread; with the advent of the electronic record the input of every provider in every specialty (and everything that results from it) can now be documented and the value that we each bring patient care can now be determined objectively (and jointly) based on hard data. This function of the EMR would be somewhat analogous to abstracting patient records for coding/billing purposes, and there is absolutely no reason why we should not be moving towards this model of “data-driven” valuation.

Let’s consider patients customers, but at the same time let’s get real.

Have you ever been a patient? What about someone close to you?
Have you ever been really sick? Have you ever had a life-threatening illness?
Did you, a friend, or a family member ever need to go the hospital “right away”?

The point of asking these questions of course is to underscore the reality that the circumstances under which we make our decisions concerning utilization of health care services may be a matter of some urgency, and they do not lend themselves to the value model proposed by PT. An elective colonoscopy is another matter, but do we really want to further fragment the patient health care record?

So what do we all value in health care? We desire high quality relationships!

I think it is fair to say that we all want to deal with doctors that we can trust, with someone who know not only about medicine but someone who also knows us, and who cares for us; a doctor who is looking out for us, helping us, guiding us, keeping us from harm, and if possible making us better.

More than anything else we (patients and their doctors) have lost relationship. Patients have lost physicians serving as their advocates. I am not suggesting that it is desirable or practical to return to a “paternalistic” model of medical practice, but if we consider the entire spectrum of patient-consumers, I think it is important for us to acknowledge that their will always be some patients who need more (or desire more) help than others in navigating the health care system.

Allow me to suggest that an important component of the value proposition in health care delivery can be expressed in terms of the quality of the relationship that exists between a patient and his or her doctors, as well as the relationship that exists between the patient and the health care organization.

In terms of health care economics / health policy; are there any practical means of supporting or building better relationships (as a measure of value? or of quality?)

1. Multiple Conditions. On Gail’s central point about Porter & Teisberg’s “value based competition” being based on patient medical conditions not being limited to one condition but including all patient co-morbidities, Gail, Mike and Elizabeth are actually in total agreement. All conditions affecting a patient are the focus of P&T’s idea, not one. Indeed, that is a key reason Mike and Elizabeth spent so much time with Dr. Toby Cosgrove, other doctors and others at the Cleveland Clinic in preparing their book. The Cleveland Clinic of course specializes in treating patients with multiple conditions.

2. Implementation. On the lack of detail in getting from “here” to “there,” Mike and Elizabeth I suggest provide an extraordinarily important, very unconventional and undoubtedly controversial solution to how to get many things done quickly and broadly and with great benefit to patients and many others.

Don’t make the make the “totally innocent” or “naive” mistake Uwe Reinhardt colorfully but importantly makes in his comment, and propose government solutions that PACs and other political actors will certainly affect. As I detail in my blogs on Uwe’s and Jamie Robinson’s comments and in my book chapter on P & T’s model “Science Teams By Disease When Ill,” Mike and Elizabeth’s breakthrough private market solution does not require government action at any of the 53 levels of government normally involved (Federal, state, DC and Puerto Rico, plus local governments some times too).

No government legislation or action required.

Further, because P & T’s central focus is patient’s with know n disease systems, as a legal matter payments to providers is not insurance subject to state insurance department regulation for at least 50% of health care spending. Thus implementing their model is greatly simplified in many contexts.

For those unfamiliar with private solutions, I suggest Charles Schultze’s classis The Public Use of Private Interest (Brookings 1977) in general. On how quickly and broadly they can take affect, I suggest first reviewing how PPO benefits and networks grew from an idea to dominance in the 1980s-90s (my point is not whether PPOs are good or bad, but as a legal and practical how private solutions can work). As to the potential impact of private solutions, I suggest the CBO’s report that private market innovations including PPOs in the early 1990s caused “the slowest rate of growth in [national health care spending] in over 30 years.”

(In the interest of full disclosure, I was privileged to help Mike and Elizabeth over the last six years. I was so smitten by their idea I wrote a book chapter “Science Teams By Disease When Ill” on practical aspects of their idea in Unique Value published in 2004, and now run a company implementing their model called Next Generation Healthcare, LLC.)

An unexamined patient is not worth treating. Thus the same way an unexamined problem in healthcare is not worth solving.

Technology is commoditized in healthcare and thus leading it into some dominant platform that no one can access. We need to make healthcare services commoditized so that it instantly becomes available to everyone which is to everyone’s benefit, except of course to the dominant platform owners.

For a proper Win-Win situation we need a total of two thing: competition + co-operation. This is many a times also termed as co-opetition.

Nothing is more useful than water; but it will purchase scarce anything; scarce anything
can be had in exchange for it. A diamond, on the contrary, has scarce any value in use;
but a very great quantity of other goods may frequently be had in exchange for it.
— Adam Smith, Wealth of Nations, 1776

Two hundred years ago, Adam Smith presented a paradox concerning water and diamonds: Water is essential to life, while diamonds are not. Yet water is essentially free, while diamonds, alas, are not.

We are all iterating the same point in this case. We all are mentioning that value based approach towards patient health is the future of healthcare. At the end our goal is to improvise the current healthcare system by defining proper processes and approach mechanisms.