How quickly—and well—can the U.S. healthcare system re-envision and rework itself? That profound question was at the substratum of a dynamic keynote discussion on May 2 at the World Health Care Congress, being held at the Marriott Wardman Park in Washington, D.C. Tuesday morning’s first keynote panel discussion, entitled “Propel the Shift to Value-Based Care: The Forefront of Financial Sustainability, Cost Reduction, and Outcomes Improvement,” was moderated by Robert Pearl, M.D., executive director and CEO of The Permanente Medical Group, the physician organization component of the Oakland, Calif.-based Kaiser Permanente organization.
Pearl was joined by Michael Tarnoff, M.D., a practicing surgeon and the CMO of Medtronic Americas, and by Kurt J. Wrobel, CFO and chief actuary at the Danville, Pa.-based Geisinger Health Plan. The three plunged immediately into a dynamic discussion of some of the thorniest issues around the shift from a fee-for-service payment-based U.S. healthcare system to a value-based one.
“The idea of value-based care, to me, is both complex and simple,” Pearl said at the outset of the panel. “Want to know how complex it is? Spend a Saturday reading MIPS and MACRA. But I also think that we have to keep our eye on the fact that it’s simple. Preventing a stroke by managing hypertension is better than going in and retrieving a clot from the carotid artery. But that’s not the way we treat people in this country. Only 55 percent of people with hypertension have it under control. And only half of the people are screened for colon cancer, so that twice as many people die every year,” Pearl noted, among other statistics that he shared. Indeed, even with those sub-optimal outcomes, “Our care is still 50 percent more expensive than in other countries,” he said. “Prevention, medical errors, disparities based on race, account for 500,000 deaths every day. The government will spend over half of its tax revenues on healthcare, which can’t go on.”
Continuing, Pearl asked, “So how will this change happen? How can we accelerate the change, and what will be the impact upon physicians, upon hospitals, and upon the overall healthcare system?”
“A couple of years ago, I began to think about what we’re talking about this morning, which is the notion of variation in care,” said Tarnoff. “I was called in to see a young woman with abdominal pain. That generally equates to a CAT scan. She did have appendicitis. I came in in the middle of the night, performed a minimally invasive appendectomy, made a couple of very small incisions, took out her appendix, and six hours later, she was up and walking and on her way home. And our chief resident said, ‘It’s a good thing you were here tonight Mike; if we had had a regular trauma surgeon on call, they would have done an open appendectomy and she would have been here for at least a few days.’ And I thought, gee, that’s not fair. Why is the standard of care not in place? We shouldn’t allow for variation to dictate that that young woman gets different forms of treatment [based on variations in situation]. I can pull up on my phone evidence-based literature. But we don’t rely on that; instead, we end up with a high degree of variation in practice and decision-making, which leads to variation in outcome, and there you have a simplistic view of why things are so variable. So I began to look at Medtronic about how we could look at variation and change it. Variation as the enemy of quality, and the need for non-traditional partnerships to fix it.”
“I’ve spent my whole life as an actuary, and recently became chief actuary at Geisinger Health Plan,” Wrobel said, by way of introduction. “We’re not a traditional health insurer; our insurance is tightly connected to a clinical enterprise. The other piece of this, in looking at these questions as an actuary, is to think about the underlying risk we’re taking. And what we’re trying to do at Geisinger is to make the financial arrangements so that we can improve the quality of care and reduce variations. And where we ultimately want to take this program is less about the financing piece and more about the kinds of things Michael is taking about.
Even in 2017, Pearl said, “Half of the hysterectomies are open, whereas the most value-based organizations are doing it minimally invasively; gastric cancer is the same. What are the specific things you’d recommend to make it happen? I want to know the exact steps.”
“I do like to make things simple,” Tarnoff replied. “How about if we follow the data and the evidence? Where we have evidence and data and proof points that a particular standard or care path should be followed—category one is, what do the data and evidence suggest should be the standard of care? And how far are we from being where we should be? I’ve seen hysterectomy done as an outpatient procedure: you come in in the morning, have a minimally invasive hysterectomy, go home the same day. I wasn’t surprised it could be done, but was surprised it was happening. So I got on a plane, and went to see it being done. Then I got on a plane and saw minimally invasive bariatric surgery. So we know that those surgeries are happening,” he said.