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Swimming Upstream: Creating a Culture of High-Value Care

Gupta, Reshma MD, MSHPM; Moriates, Christopher MD

doi: 10.1097/ACM.0000000000001485

As health system leaders strategize the best ways to encourage the transition toward value-based health care, the underlying culture—defined as a system of shared assumptions, values, beliefs, and norms existing within an environment—continues to shape clinician practice patterns. The current prevailing medical culture contributes to overtesting, overtreatment, and health care waste. Choosing Wisely lists, appropriateness criteria, and guidelines codify best practices, but academic medicine as a whole must recognize that faculty and trainees are all largely still operating within the same cultural climate. Addressing this culture, on both local and national levels, is imperative for engaging clinicians in reforms and creating sustained changes that will deliver on the promise of better health care value. This Perspective outlines four steps for health system leaders to understand, cultivate, and maintain cultural changes toward value-based care: (1) Build the will for change through engaging frontline providers and communicating patient-centered motivations for health care value; (2) create necessary infrastructure to support value improvement efforts; (3) expose physicians to value-based payment structures; and (4) demonstrate leadership commitment and visibility to shared goals. The authors support their recommendations with concrete examples from emerging models and leaders across the country.

R. Gupta is a VA/UCLA Robert Wood Johnson Clinical Scholar, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, California, director, outreach and evaluation and director, Teaching Value in Healthcare Learning Network, Costs of Care, Boston, Massachusetts.

C. Moriates is assistant dean for healthcare value and associate professor of internal medicine, Dell Medical School at The University of Texas at Austin, and director of implementation, Costs of Care, Boston, Massachusetts.

Funding/Support: R. Gupta is supported by the U.S. Department of Veterans Affairs (VA) Office of Academic Affiliations through the VA/Robert Wood Johnson Clinical Scholars Program.

Other disclosures: C. Moriates receives royalties from McGraw-Hill.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Reshma Gupta, Department of Medicine, 10940 Wilshire Blvd., Suite 710, Los Angeles, CA 90024; telephone: (310) 794-2268; e-mail:

The writer David Foster Wallace once told a parable about two young fish who meet an older fish who nods at them, and says, “Morning boys, how’s the water?” The two young fish swim on, and then eventually one of them looks over at the other and asks, “What the hell is water?”1 Sometimes the most obvious, important realities are the most challenging to talk about.

Organizational culture, like the water surrounding fish, is all around us, yet can be difficult to perceive from within. This culture or “imprinting”—defined as a system of shared assumptions, values, beliefs, and norms existing within an environment—creates a powerful undercurrent that shapes the practices of all health care providers and contributes to overuse within the health care system.2,3 Recent work to improve health care value focuses on creating guidelines and algorithms, such as Choosing Wisely lists and appropriateness criteria. Although it is important to codify best practices, we must recognize that, even with such guidelines in place, we are largely still swimming in the same cultural “water.” For example, in a recent study of emergency physicians and trainees, 97% of respondents reported ordering unnecessary imaging tests, most often reflecting a cultural response to uncertainty rather than a physician’s lack of knowledge or judgment.4 Dzeng and colleagues5 found that institutional culture and policies similarly affected whether medical trainees felt compelled to offer the choice of resuscitation in all clinical situations regardless of whether they believed it was clinically appropriate. To change clinician behaviors in a way that will deliver the best care at lower cost, the culture within health care microsystems needs to be meaningfully addressed. In this Perspective, we outline four steps for health system managers (i.e., division or practice leaders and quality or value officers) to begin to understand, cultivate, and maintain culture change toward value-based care: (1) building the will for change, (2) promoting infrastructure to achieve successful change, (3) exposing physicians to alternative incentive or payment structures, and (4) demonstrating leadership commitment and visibility to engage physicians. We believe that progress within each step is dependent on growth within the other steps, on other divisions or practices within the health system, and on executive leadership support through an iterative process.

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Building the Will for Change

Health systems are now incentivized to deliver value over volume to populations. While many health system executive leaders are strategizing the best ways for their institutions to deliver on this goal, it is imperative that frontline providers are directly engaged in the effort because they are the face of patient care. As the well-worn business adage states, “Culture eats strategy for breakfast.” Spreading the drive for value-based care to all health care workers is a decisive step. Providers must see the difference between their own practice and a high-functioning center of value-based care delivery through honest feedback and internal transparency.

Building collective motivation among physicians often requires champions who share their individual internal motivations, which usually stem from a desire to improve care for patients, serve a community, or be a part of the movement to improve health care quality while lowering costs. Many physicians aspire to be compassionate providers with the mind-set of helping their patients reach long-term health goals, rather than merely increasing throughput, patient volumes, or revenues. Thus, physicians are more likely to respond positively to a focus on value that incorporates the patient perspective: delivering enhanced quality, safety, patient experience, and affordability.

Prior social movements illustrate how public culture can also be leveraged to support transformational success in health care reform. By the time policy was enacted in the tobacco cessation movement, for example, societal attitudes were already at a tipping point. Similarly, the value movement in health care has reached a junction where most stakeholders are aligned and ready for change. In a 2015 Gallup poll, health care costs were the biggest financial concern facing U.S. families.6 In addition, in a 2013 study, although only 36% of surveyed physicians claimed to have “major responsibility” for health care costs, 85% of physicians believed trying to contain costs is the responsibility of every physician.7 Frontline clinicians, managers, and executive leaders interested in promoting value-based care should leverage these changing societal tides as motivators for enacting programs and policies.

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Promoting Infrastructure to Achieve Successful Change

Frontline providers and managers must have the infrastructure to support high-value care decisions to create successful cultural transformation. For instance, six years after patient-centered medical homes were promoted as a model that would reinvigorate primary care, outcomes now vary widely across demonstration sites. Wagner and colleagues8 found that practices with sustained cultural changes and improved outcomes were those that had the infrastructure to enable system-level changes. Institutions will need to support management roles in value improvement and population health, create and maintain new health information technology (HIT) and continuous process improvement training, and introduce value-promoting incentives for clinicians. Executive leaders can also recruit and develop leadership pathways for faculty and staff to foster growing leadership in value promotion within the medical center.9

Kaiser Permanente, Geisinger Health System, and Group Health Cooperative have invested in robust HIT systems to systematically change workflows, monitor real-time provider practice patterns, and develop patient registries. With these efforts Kaiser, for example, has reduced stroke deaths by 42% over nine years in Northern California, scored better than over 90% of the nation on cholesterol management in patients with cardiovascular disease, and reached blood pressure goals for 86% of their hypertensive patients compared with 52% nationally.10,11

The University of California, Los Angeles (UCLA) has introduced an organizational structure in which physicians from each division are named as quality officers. These quality officers work with central support teams to develop customized analytics, target measures across a full patient treatment episode, and stimulate a cultural shift.12

Trusted performance measures and explicit approaches to test practice changes are crucial elements for showing providers that their efforts are successful and for propagating further culture change. The UCLA program emphasizes the importance of condition-specific, clinician-guided measurement,12 which is similar to the composite score called “perfect care” that is employed at the University of Utah. For instance, in orthopedic surgery at the University of Utah, the cost of joint replacement surgery, performed by 10 different surgeons, used to vary by as much as $19,000. To address this problem, surgeons agreed on a set of care standards that together would define “perfect care” for the patient. Under this program, the percentage of patients reaching this standard has risen from 40% to more than 80%, while direct patient care costs have simultaneously fallen.13,14 Measurement, however, must also include evaluation of unintended outcomes of cost reduction (i.e., quality and access measures) so that providers trust that the care delivery changes do, in fact, improve their patients’ outcomes.

Despite these emerging measures of value, there is currently no systematic method for monitoring high-value care culture change within programs. Because culture is a driving undercurrent shaping clinician practices, delivery systems and clinician groups could benefit from a tool that would help them identify target areas specific to their environment. This tool could be used to generate benchmarks and provide action-oriented feedback related to improvements that have been shown to promote a culture committed to providing the best care at lower cost.

To create more rapid improvement, many medical centers are also engaging in learning collaboratives to catalyze shared innovations. The High Value Healthcare Collaborative, a consortium of 13 health care delivery systems and the Dartmouth Institute for Health Policy & Clinical Practice, has created a data trust that includes a number of “marts” customized for specific conditions.15 The Teaching Value in Healthcare Learning Network, which is sponsored by the nonprofit Costs of Care and the American Board of Internal Medicine Foundation, is a community of health system managers and educators who share educational resources and strategies related to teaching health care value.16 Whether collaboratives will result in sustained improvements for creating a high-value care culture is currently unknown.

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Exposing Physicians to Alternative Incentive or Payment Structures

Value-promoting incentives and payment structures may help support a high-value care culture. Physicians who are paid by alternative payment methods tend to recommend fewer visits and services than those who are paid under fee-for-service models.17 Groups such as CareMore, paid by a capitated model under a Medicare Advantage population, have introduced value-promoting physician payment incentives. Providers receive payment adjustments based on their quality and efficiency. Under this payment model, CareMore has reduced their average hospital length of stay (from 5.2 days to 3.7 days) and 30-day readmission rates (from 18.4% to 14.7%) despite caring for a higher-acuity patient population.18 Preliminary data also suggest better patient care quality outcomes, including a 60% lower amputation rate for diabetic patients compared with the national average, and a 4% pressure ulcer rate in institutionalized patients compared with an average of 13% in the state.19

CareMore’s chief executive officer, Dr. Sachin Jain, has described that this payment model allows a freedom to fund whatever is truly necessary to manage a patient’s medical conditions, even purchasing a mini-fridge to store insulin, or an air conditioner for a frail elderly patient to achieve long-term care goals.18,20 The Veterans Health Administration (VA) system has invested in new programs, such as patient-aligned care team models, that aim to prevent unnecessary health care utilization over time,21 and some centers are relying on new roles such as health coaches or care managers within these systems to increase patients’ access to their health care team.

However, simply shifting payment models will not be enough to meaningfully affect culture. For many decades the VA has employed salaried clinicians who are not paid based on volume, yet there are still plenty of areas of overuse throughout this system. In addition, recent events involving the VA raise concerns about the trade-offs that could arise between cutting costs and quality of care.22 Others have worried that financial incentives may actually crowd out the intrinsic motivation of physicians to do what is best for their patients.23

Many medical centers are currently at a crossroads, adopting new models of care while still receiving a high proportion of fee-for-service payments. This is particularly evident at academic medical centers that serve as subspecialty referral care centers. However, it seems clear that the balance will continue to tilt toward an increasing share of value-based payments in the future. As this happens, so-called “destination medical centers,” or health systems with active efforts to have a global reputation for health care excellence and patient-focused outcomes,24 will likely be those centers that can show they deliver the highest value. For example, Boeing in Seattle chose to contract bundled payments for knee and hip replacements with the Mayo Clinic in Arizona and cardiac surgeries with the Cleveland Clinic over local care centers, because of their belief that this would lead to better value for their employees.

Considering looming shifts to value-based payments, exposing physicians to alternative care models now is important to support the development of a high-value care culture. Although value-based payment models and incentives are not a panacea, they are a powerful tool to be wielded carefully in fomenting a culture change that supports value.

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Demonstrating Leadership Commitment and Visibility to Engage Physicians

Leadership visibility in the transformation process is also critical for eliciting culture change.5 Managers (i.e., quality or value officers) who engage with frontline providers and other health professionals create a unified message and set cultural expectations that support innovation, a willingness to try new things, and open communication at all levels of training. Although executive leaders often cannot single-handedly create culture in their institutions, they certainly can design the conditions for a great culture to emerge.

Cultural challenges can be exceedingly complex and require long-term commitments from leadership and clinicians. To maintain the vision, providers require faith in their managers, executive leadership, and proposed ideas.8 Whereas top-down decrees for specific changes may not align well with the realities facing frontline health care workers, efforts that “pull” ideas and enthusiasm from these workers and provide a bridge to institutional resources are likely to be more potent at generating behavior changes. This tactic has been successfully employed through crowdsourcing-based initiatives, such as the “Caring Wisely” program at UCSF and the national Teaching Value & Choosing Wisely Challenge.25,26 These programs cultivate, curate, and disseminate the best ideas from the field for improving value, displaying the importance of bidirectional communication about where areas for improvement exist.

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Culture change is required to mobilize delivery of high-value care. Although it can be challenging to take the dive into the murky waters of culture transformation, the approach outlined above can foster an environment conducive to engaging providers in changing norms within programs. Moving forward, we must look beyond guidelines alone and address the undercurrent of culture that guides physician behavior to create physicians skilled in delivering high-value care for our future health care system.

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