OBSERVATIONS - October 9, 2007

New Health Affairs Paper Raises Questions About Value and Values in Health Care

In a new paper published in this month’s Health Affairs, Alain Enthoven, Jay Crosson, and Steve Shortell continue a debate about what constitutes value in health care. Their paper comments on the recent book “Redefining Healthcare: Creating Value-Based Competition on Results” by Michael Porter and Elizabeth Teisberg, which put the issue of “value” on the table so prominently. Porter and Teisberg argue that health care providers should compete with one another in groups called “integrated practice units” (IPUs), organized not around provider specialty but around patients’ conditions. In their model, one group would provide all the care necessary to treat patients with diabetes, another would provide all the care necessary to treat patients with depression, and so on. These groups would compete with one another, and patients would be able to choose freely among them, selecting the very best providers for each of their conditions, rather than having their choices constrained by the network restrictions in place today.

It is not surprising that this vision of competing, disease-specific provider groups, which Enthoven and colleagues refer to as “archipelagos,” raises the hackles of the advocates of integrated delivery systems. Porter and Teisberg’s vision stands in direct contrast to the ideal long put forth by Enthoven and colleagues, in which large, integrated multispecialty groups of clinicians provide all necessary care for a defined group of patients. In this model, consumers choose a medical group, not necessarily a disease-specific provider (although that can happen, too). Enthoven and colleagues argue that Porter and Teisberg’s IPUs could work if patients only had one condition at a time. But because so many patients have multiple co-morbidities – diabetes and depression and heart disease, in addition to the need for everyday primary care – it makes more sense to create a “one-stop shopping” experience for patients, where providers from all disciplines collaborate, share common patient records, and share financial incentives so they are not working at cross-purposes with one another.

I won’t further recapitulate the arguments put forward by Enthoven and colleagues, nor by Porter and Teisberg on this subject. Instead, I would encourage readers to get this information from the source. But, although I have been involved in this debate for some time, I was struck by something new as I read this latest paper from Enthoven, Crosson, and Shortell. While they (and Porter and Teisberg) are writing about value in health care, what it really comes down to is a difference in values.

“Value” is a much-debated term, but most would agree that it has something to do with quality-for-money, and that the most quality for the least money equals the best value. It’s basically an economics term. But by adding an “s,” we get “values” – deeply embedded beliefs, preferences, and cherished ideals by which we live. It’s more of a philosophical term.

The Enthoven/Porter divide (for lack of a better term) is essentially about values. Both camps greatly value free markets and consumer choice, so there’s no disagreement there. But the question is…what other values are to be supported and nurtured by those free markets? Porter and Teisberg’s vision puts a lot of weight on the value of experience/expertise. One of their most compelling arguments for IPUs and against multispecialty groups is that no group can be the best at everything, and consumers should be able to choose the best providers for each condition, regardless of network boundaries. (Would you rather have your transplant performed by a doctor who’s done it a thousand times, or one who’s done it just a handful of times?) But, Enthoven and colleagues counter that the list of procedures for which the volume-outcomes relationship has been proven is rather short. Further – and this is where values come into play – organization into disease-specific groups may compromise the other important values of disease prevention, overall system efficiency, consumer convenience, and continuity of care.

In the end, the debate about the best way to organize the health care delivery system has to be about what we value as a society. Intentionally or not, the most cherished value reflected in our current health system seems to be maximization of revenue, not health. Enthoven and Porter, and their respective colleagues, present us with alternate visions of markets that reflect different values. They should all be commended for doing so.

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