Harvard Professor Michael Porter, PhD, has crafted persuasive arguments for the creation of true value-based systems in both healthcare and corporate business.
Provocative as they are, Porter's principles can go even further to influence essential change in how economics intersect with society for the greater good and health of the nation by putting a sharper focus on the role of the consumer/patient in improving health and health care. Porter's well-developed and publicized ideas are resonating with business and policy leaders and may help shape the health care reform debate, making it essential that we in neurosurgery consider their potential impact.
In his Jan/Feb 2011 Harvard Business Review article, “The Big Idea; Creating Shared Value,” Porter artfully describes his proposed solution to the erosion of trust in the corporate world and the consequences of that erosion in terms of economic prosperity.1 Porter defines shared value as a principle that “creates economic value in a way that also creates value for society by addressing its needs and challenges.” In this scenario, companies take the lead in a new model that ensures economic success through corporate collaboration with and investment in communities. Such relationships would require consideration of a product's benefit to the consumer and to the needs of society as a whole.
In an earlier article, “A Strategy for Health Care Reform—Toward a Value-Based System” published in The New England Journal of Medicine in 2009, Porter describes a way to increase value for patients by using efficiency and measurable health outcomes.2 This approach encourages increased quality and comparisons based on outcomes data.
In this model, health care would be organized around medical conditions, and the full range of needs for that condition would be addressed. Success for providers, including insurers, would be achieved only when value is delivered. This approach relies most heavily on providers to create the value-based system.
Taking Porter's concepts in both of these articles one step further would be the notion of “shared health care value,” in which all the stakeholders in the system for providing health care products and services are equally responsible for creating value, including doctors, medical personnel, insurers, hospitals, employers, unions, and patients and their families.
Under this scenario, providers would have a responsibility to ensure that consumers have access to the full range of care—and not just the treatment of disease. Employers would have a responsibility to motivate employees to take good care of themselves. And patients would be rewarded with lower insurance rates—and better overall health—for practicing healthy behaviors, sharing the responsibility for their health with the other stakeholders.
Porter's concept of shared value recognizes that societal needs define markets and that social harms or weaknesses can be costly to business in terms of wasted energy or resources. He claims that addressing these needs can drive innovation and productivity and expand markets.
In the same way, shared value in health care assumes that poor health, preventable disease, and a lack of access to adequate health care in a community creates inefficiency and is costly for all. When these problems are tackled with creative and collaborative approaches, health outcomes improve, resources are used more efficiently and stakeholder costs are contained.
Porter also considers that while businesses have learned to parse and manufacture demand, they have lost sight of key questions: is the product good for the customers, and does it meet societal needs?
We can ask the same of our health care system and our approach to neurosurgery. When a hospital builds a costly surgical program but fails to also provide the kind of preventive and rehabilitative programs that reduce morbidity and mortality, does it promote long-term health in the community?
As examples of innovators that are creating shared value, Porter cites high-tech companies finding ways to economize on power usage or banks helping customers manage credit and pay down debt. Porter adds that meeting needs in underserved markets often requires redesigned products or different distribution methods, which can trigger fundamental innovations that can have application in traditional markets. He cites microfinance to serve unmet financing needs in developing countries, an approach now filling a previously unrecognized gap in the United States.
These lessons are applicable in health care generally and in neurosurgery specifically.
While neurosurgery is a discipline in which some patients have no control over the circumstances of their illness, those with brain tumors and vascular malformations for example, the majority of our patients, seek care for conditions over which they do have some control. For patients with spine problems and stroke, lifestyle factors often contribute to the disease, yet patients ultimately expect to be “fixed” by providers within the health care delivery system.
Using Porter's value-based health care system, a redesigned degenerative spine program would include investments by stakeholders in the full spectrum of care to ensure patients have a major role in their own wellness before, during, after, and even instead of any surgery. This program may include nutrition education, physical therapy, and other preventive interventions.
Employers, for their part, would ensure safety measures are developed and maintained to safeguard against back injuries on the job and provide incentives for employees to maintain healthy lifestyles. This approach would create shared health care value by engaging employers and patients in health promotion. Neurosurgery outcomes for degenerative spine disease would be improved when patients' overall health has been improved.
Indeed, changing the framework from which we think about disease creates shared health care responsibility. A neurosurgery stroke program, for example, would produce shared health care value when it involves all stakeholders in the provision of nutrition education—low-fat/low-cholesterol diets, blood pressure control, weight-loss instruction, exercise, and smoking cessation classes.
Porter's concept of value-based health care relies upon the measure of outcomes over the full cycle of care of the medical condition, not separately for each medical intervention. That means survival is only one thing to measure; the degree of health or recovery achieved and the time taken to achieve wellness also would be considered. Outcomes measurements would be the same in a shared valued-based system, and all of the stakeholders, particularly patients, would have an explicit incentive to aim for excellent outcomes. Creating shared health care value requires shared responsibility.
Edie E. Zusman