Profit motives and healthcare delivery

This morning I had the opportunity to spend time with a group of 2nd year medical students facilitating a patient/ family case for their Life Cycle Unit.  In this particular case, the students had just under two hours to work their way through how to provide healthcare to a young (well, younger than 40) man with a chronic health issue.  The intent of the case, as I understood it, was to get the students to consider healthcare options available to those who are economically marginalized through job loss; the case took some twists and turns from unemployment to underemployment to the patient’s family losing their home.  At each step of the way, the students were to consider what options were open to the patient to get his medications and follow-up care that he needed.  While I was impressed at how quickly they managed to access resources- one of them going so far as to make a quick phone call to get more information on a program- I was more impressed at their ability to cast this man’s ability in the broader context of how we deliver healthcare in the U.S.  The truth is that he was designed to fall into one of our “gaps” where healthcare coverage is expensive to obtain, and the students truly understood the implications of that.  They also expressed frustration that we live in a country where someone’s family can be working hard and doing the right thing, yet healthcare is still a commodity for them.  The students really left their politics at the door and discussed these things from the perspective of people who are responsible for the care of other people- and trying to puzzle their way through how to do the “right” thing for this man when faced with a series of challenging circumstances.

I had the opportunity earlier this year to hear Thomas Lee, the CMO of Press Ganey, address the issue of the future of healthcare; he’s someone who has some important ideas, though they are also ideas that would require a fundamental change in how the healthcare system in the U.S. is aligned.  In October, 2013, Dr. Lee and Michael Porter published “The Strategy that will Fix Health Care” in the Harvard Business Review.  If you haven’t had the chance to read it, it’s worth the time and effort to get a copy of the article.  To give you the short version, their fundamental premise is that healthcare delivery is threatened by rising costs and uneven (at best) quality of care.  They acknowledge that while efforts have been made to fix the things that are broken, none of these incremental efforts have met with much success.  Their core strategy?  Maximizing value for patients- delivering the highest quality care at the lowest cost.  They believe we need to put in place a “value agenda” in order to save healthcare from itself.

The move towards value in care is already happening.  At my own institution, it’s under the aegis of “Value Driven Outcomes” (VDOs) as a system priority.  However, for the value agenda to really work, it seems to me (and my students) that two fundamental things have to happen:

  1. Everyone involved in the delivery of care (not just clinicians, but facilities, drug and device companies, etc.) has to have the same motive- to provide best care to the patient.
  2. In order for 1 to really happen, the profit motive needs to be either removed or contained.  Certainly the caps on drug prices in the EU represent a first move in this direction- one that isn’t capitalistic by any means, but the only clear way forward to focus fully on patients as the raison d’être for the healthcare system in the first place.

With that likely controversial statement, I’ll close- and, of course, ask for thoughts, particularly if you can see a way to maintain any significant profit motive with the primacy of the value agenda for our patients.