Avoiding the Unthinkable: A Tale of 2 Triangles and the Process of Care They Govern

May 2008, Vol 1, No 4 - Editorial
Robert E. Henry
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Last month, 2 back-to-back meetings brought out some of the leaders driving the transformation of healthcare into a value-based, patient-centered system. The Academy of Managed Care Pharmacy (AMCP) went first, celebrating its 20th anniversary, followed by the 5th Annual World Health Care Congress (WHCC). Both sessions revealed just how different, and better, healthcare is becoming. Even the warnings about the catastrophic consequences of not improving our healthcare system were accompanied by numerous remedies for it. Said one speaker, "If you can't imagine things getting that bad, they probably won't."

There is some truth to this. In the face of improved evidence gathering, analysis, and application, it is getting harder to sit back and watch healthcare inefficiencies—clinical or economic—get bad. There are simply too many constructive remedies being proposed. We outline some of the advances proposed at the AMCP meeting in this issue of American Health & Drug Benefits (AHDB). Evidence-based medicine is finally making its appearance in value-based benefit designs. Data-gathering techniques are improving to the point where healthcare providers and managers can track the effects of shifts in formularies and benefit designs. Patient adherence is finally moving from a pipe dream to a hard metric, fortified by a dizzying array of payorgenerated tactics keeping patients connected with health "coaches."

This is not your father's healthcare system.

And so, because reasonable people are seeing real data showing what will happen to healthcare costs and outcomes if new efficiencies are not instilled into the practices of every stakeholder—from patient to provider, payor to purchaser, manufacturer to regulatory—it is becoming sensible to conclude that things are not going to get that bad. We are not going to spend an unsupportable proportion of the US gross national product on healthcare midway through the century. We are not going to continue spending twice as much for identical healthcare outcomes in Miami as we do in Minnesota. And we will not apply population-based data on all patients as if everyone were an average patient. People are rational beings and, when confronted by the unthinkable, will alter their course, not freeze like so many deer caught in the headlights of spiraling costs and intractable local customs.

As we witness the transformation of healthcare from expert-based opinion to evidence-based, value-based, patient-centered care, it becomes apparent that while processes are changing, the principles that support them are constant. The new research presented at the 2 conferences locks in on the eternal triangle of value: cost, quality, and access. So said Dr David Brailer, health information technology (HIT) expert, at his AMCP presentation. It is the balancing of these 3 interlocking forces that drives value.

AHDB organizes information on the basis of this and a second triangle: clinical, business, and regulatory. When value propositions are defined by a given healthcare intervention, that product or service must be delivered through formulary and benefit designs that satisfy a similar balance of clinical, business, and regulatory criteria. Circumstances and resources are in dynamic flux, but healthcare resource allocation is driven by these unchanging principles.

At these meetings, presentations revealed stunning new opportunities for value, with quality of research that was unthinkable even 5 years ago, and the trend can be expected to continue indefinitely. Observational data and HIT supplying it are bringing the promise of evidence-based medicine to formulary and benefit designs. Data were presented showing the differences in adherence rates across a range of medications used for the same condition, and the different overall healthcare resources consumed by the different patient groups. The ability to track patient adherence, outcomes, and health care resource allocation with such granularity is making health benefits able to serve the patient and the healthcare system alike, empowering all stakeholders to know exponentially more about the impact of healthcare interventions than was ever possible. This is good news for those caught in the glare of the headlights warning that spiraling healthcare costs were about to overrun the entire system and effectively wipe it out.

But back to that persistent value triangle of cost, quality, and access: the impending "collision" is not just with undesirable healthcare costs, but also with substandard quality of care and access to it. The new systems for gathering and analyzing data on the quality of care and the adherence (access) to treatment regimens are integral for delivering best practices at best costs. Researchers are able to assign cost values to failing to provide optimal drugs or devices or to perform appropriate diagnostic tests. They can assess the impact on healthcare resource utilization of poor patient adherence to optimal treatment regimens. The sentiment is old—C. Everett Coop's admonition that the least effective drug is the one never taken—but the ability to assign outcome metrics to it is new, empowering all stakeholders to do something about it. This technology is not getting rid of expert opinion but rather empowering experts to produce an evidencebased paradigm, armed with better facts than was ever possible before. Data are never self-explanatory, but expert analysis will help unravel the huge disparities in treatment costs and outcomes of patients in different parts of the United States—even in different areas of the state of New Jersey, as Dr Uwe Reinhardt reported at the recent WHCC.

Thus, the quality of the Great Healthcare Debate on what benefits should be covered, and how, is increasing. Doomsday "chic" one hopes is on its way out, progress on its way in, as researchers replace a cost-centered approach to managing spiraling costs with a value-based approach: the cost-quality-access triangle. By putting these elements first—by putting the patients' needs, even the individual patient's needs, first—costs will become manageable. Runaway healthcare costs back in the 1990s were addressed by the HMO strategy, "just say low." This cost-minimization, race-to-the-bottom strategy did not resonate with patients or their providers. Evidence-based medicine then began to emerge, but only as a gauge of clinical quality. It became necessary to complete the triangulation of forces—cost, quality, access—by linking empirical quality care with access to care. This guides payors and purchasers alike on the truly acceptable opportunities to rein-in costs. Just how those models will take shape is yet unknown. What is likely is that they will be realistic, and that outcomes, health and economic, will be verifiable.

At the end of this scenario is the integration of stakeholder activities and agendas. Each party to the process of care is vitally interested in protecting its interests: patients, providers, payors, purchasers, manufacturers, regulatory, political, academia, evaluators, distributors, investors. Aligning the incentives of this multilateral group will require a collegial spirit currently absent from the Great Healthcare Debate. The quality of evidencebased outcomes should help make meaningful transparency possible, along with the redefining of responsibilities of each stakeholder group to the others, always in support of the patient, the patient, the patient. The fate of the 21st-century patient—which ultimately is us—will be determined in a more informed healthcare environment than ever existed.

The vitality of ideas expressed at this year's healthcare meetings and in the pages of this journal provides evidence of a resourcefulness that has never left healthcare. For a time, the rush to progress seems drowned out by the glare of those frightful headlights warning of imminent doom. But the unthinkable is providing ample incentive to sidestep it. Experts are coming forward with propositions and systems for achieving healthcare progress never before imagined, and with results that are already taking root in our emerging new system of care. It is a good time to be alive, and because it is human nature not to accept the unthinkable, better times lie ahead.

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