AANS Neurosurgeon | Volume 27, Number 3, 2018


Understanding Value-Based Healthcare

“Understanding Value-Based Healthcare.” Christopher Moriates, MD; Vineet Arora, MD; Neel Shah, MD. McGraw-Hill Education. New York. 2015.
Get ready for the switch from volume to value! This book is the best-to-date at defining the problems that make this change necessary while pointing at solutions. We all know the present unsustainable situation: We spend more than $3 trillion per year for health care, and at least 30 cents on the dollar is pure waste. The Institute of Medicine (IOM) define, in shocking terms, our present status: “…If airline travel were like health care, each pilot would be free to design his or her pre-flight safety check or not to perform one at all.”

Breaking it Down
The authors break down waste into divisions of unnecessary services, inefficient care due to system errors and failure to communicate, excessive administrative costs, excessively high prices, missed preventive opportunities and fraud. They estimate that we spend $83,000 per physician on insurance company interactions. Another interesting bit of data is that interns spend 12 percent of their day with patients and 40 percent of their day with computers.

The authors define value as quality plus safety divided by cost. There is an interesting chapter on the ethics of cost-conscious care, which includes a section on how to overcome the fear of rationing. They are fearful that the looming shortage of primary care providers will complicate our transition to value.

Without question, the third section of the book entitled “Solutions and Tools,” is crucial. The authors’ framework for teaching cost awareness uses the acronym COST — Culture, Oversight, System Change and Training. Culture is defined as valuing cost-consciousness and resource stewardship at the individual and team level. Oversight is defined by requiring accountability at the peer and organizational level. System change refers to institutional policy, decision-support tools and clinical guidelines. Training is defined by providing the knowledge and skills clinicians need to make cost-conscious decisions.

The book closes with stories of places that are succeeding in making the transition. I take no pride in the inclusion of Denver Health as an example. We can and must look to systems outside of health care who have modeled better ways to do things. The transition from volume to value is not an option. We must make this change, and by reading this book, you will have a guide.


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