I learned about value based health care delivery from Michael Porter and Elizabeth Teisberg more than 15 years ago. Their seminal work in this domain, Redefining Health Care: Creating Value-Based Competition on Results paved the way for me and an entire generation of medical providers and industry players to want to transform the way we deliver health care. I've spent that time, initially, trying to apply that approach with my own patients and then, more recently, with a large primary care organization. There has been definite success albeit slowly achieved. The shift from volume-based, fee for service (FFS) care to outcomes oriented and value based care (VBC) can't occur quickly enough.
Challenges in Adapting Value-Based Care
I believe that one of the drags on adaption is the manner in which medical students and residents are trained. Think about it, virtually all education and training takes place in a FFS world by physician mentors who practice primarily FFS medicine in institutions that by nature rely dearly on revenue generated through a FFS model. Most medical students and residents have no or very little formal instruction or exposure to practicing in a VBC model. It is no wonder that once out in practice they continue to apply the FFS approach. This model encourages early referrals for every medical issue that might be considered within a "specialty" domain. In reality, most specialists will treat these simple first complaints with measures that could easily be applied by Primary Care providers (PCP). However when you are trained to refer or just order a consult from a specialist there is little incentive to take that patient down the care pathway any further thus the PCP never really learns to manage those problems.
The essence of VBC is that unnecessary or ineffective, low value care is avoided. This includes ordering the wrong tests, duplicating tests or imaging, prescribing brand name drugs where generics will suffice and so on. This is most important when VBC is being ideally delivered in a full risk model. My experience has shown me that once a patient is referred out of that model, costs start to escalate and are much more difficult to manage. If the patients can be kept inside the VBC model, care is better coordinated, trust is strengthened, outcomes are improved and costs are better controlled.
Educating Providers for Value-Based Care
Which brings me back to the subject of this article. How can we train providers to practice in a VBC environment? I believe that education about VBC should start in medical school. I get that there is precious little room for adding a new subject area into medical school curriculums. But with the US spending just over $4 Trillion a year for medical care with at least $1 Trillion considered waste there is a compelling need to educate providers about the role they can play in avoiding those practices that add to waste and don't improve outcomes. Once these students enter residency training that education must continue and transition from the theoretical to the practical application of the principles of VBC. This will require that residency training programs be open to including requirements for exposure to and instruction in VBC in the clinic as well as the hospital setting. There is a growing constituency of clinical leaders that can be tapped to provide this training. Professional societies, Board certifying organizations and medical journals could support these efforts by incentivizing and offering forums for presenting VBC experiences and outcomes results.
Value Based Care is essentially about providing the right care, at the right time, in the right setting. I believe that we all started out in medicine wanting to do exactly that whether we knew it or not at the time. Let's start a dialogue about this challenge.
