We Won’t Get Value-Based Health Care Until We Agree on What “Value” Means



Some health care leaders view with trepidation the new, disruptive health care alliance formed by Amazon, Berkshire Hathaway, and JPMorgan Chase. But I’m excited because disruption is all about delivering a new level of value for consumers. If this trio can disrupt the United States’ health care system into consistently delivering high-value care, we will all owe them our gratitude.

First, their leaders — Jeff Bezos of Amazon, Warren Buffett of Berkshire Hathaway, and Jamie Dimon of JPMorgan Chase — must think deeply about what “value” actually means for the companies and individuals they will serve and for the people and organizations they will engage to deliver care.

Then they need to consider how they will bridge the divergent interpretations of value. It turns out one reason there’s been such little progress in creating a value-based system is that the stakeholders in the U.S. health care system — patients, providers, hospitals, insurers, employee benefit providers, and policy makers — have no common definition of value and don’t agree on the mix of elements composing it (quality? service? cost? outcomes? access?).

That’s the big takeaway of University of Utah Health’s The State of Value in U.S. Health Care survey. We asked more than 5,000 patients, more than 600 physicians, and more than 500 employers who provide medical benefits across the nation how they think about the quality, service, and cost of health care. We focused on these groups because we feel their voices have not been heard clearly enough in the value discussion. What we discovered is that there are fundamental differences in how they define value in health care and to whom they assign responsibility for achieving it. Value, it seems, has become a buzzword; its meaning is often unclear and shifting, depending on who’s setting the agenda. As a result, health care stakeholders, who for years thought they were driving toward a shared destination, have actually been part of a fragmented rush toward different points of the compass.

But the Utah survey’s findings also suggest a straightforward (though not simple) way to overcome this confusion: stop, listen, and learn. The most effective thing that stakeholders can do to create a high-value health care system is to pause in their independent pursuits of value to describe to each other exactly what it is they seek. Jumpstarting this stakeholder dialogue will require real leadership from executives in business, health care delivery, academic medicine, and patient advocacy groups. They’ll have to muster the courage to say to their constituencies, “The path toward value that we charted may not have been the right one.”

Those dialogues should happen at three levels: nationally, among representatives of stakeholder groups; institutionally, among partners in the care delivery process; and individually — for example, between patients and their physicians, and between employer sponsors of health plans and their employee beneficiaries.

There are several examples of the fundamental value misalignments that could be starting points for these discussions. The first concerns the relative importance of health outcomes. For physicians like me, clinical outcomes are paramount; health improvement and high-quality care are essential components of health care value. And we assume that patients share that perspective. But, it seems, they don’t. When the Utah survey asked patients to identify key characteristics of high-value health care, a plurality (45%) chose “My Out-of-Pocket Costs Are Affordable,” and only 32% chose “My Health Improves.” (In fact, on patients’ list of key value characteristics, “My Health Improves” was slightly below “Staff Are Friendly and Helpful.”) Given the chance to select the five most important value characteristics, 90% of patients chose combinations different from any combination chosen by physicians. In general, cost and service were far more important in determining value for patients than for physicians.

Frankly, I was stunned by the degree of this misalignment between patients and physicians (and, by extension, the care delivery organizations the doctors work for). This disconnect alone could account for a substantial portion of the Sisyphean lack of progress we’ve seen. But there are plenty of others. Notably, the Value survey found a striking lack of consensus on who had responsibility for ensuring that health care embodies the desired high-value characteristics. Moreover, the survey’s respondents generally displayed limited understanding of how the health care system works more than a step or two beyond their direct experience. This led to responses at odds with reality — for example, only 4% of patients and physicians recognize that an employer’s choice of health plan affects out-of-pocket costs.

Both of these kinds of misalignment — regarding the relative importance of outcome, cost, service, and quality, and who is responsible for achieving specific value characteristics — demonstrate the core problem: Stakeholders have not communicated with each other effectively, at the macro and micro levels, on what value means to them. I have two thoughts on how to start the process of getting communications and information flowing.

At the micro level, we should leverage the growing power of physician- and hospital-review systems to gather more (and more-sophisticated) information on what is most valued by individual health care consumers. Our system alone collects more than 3,500 patient comments a week. Now we need to apply our growing computational capacities to deeply mine that data both within and among systems to create an enhanced patient experience that is informed by how they define value. And business leaders should expand their companies’ efforts to track and analyze — and educate their employees about — the multiple dimensions of value in the health benefit plans they offer.

At the macro level — national, regional, and inter-institutional — major organizations should step up to convene initial rounds of stakeholder dialogues. Academic medical centers (AMCs) such as University of Utah Health are well positioned to be conveners. (The Utah Value Forum this month brought together regional stakeholders to address the challenges we all face.) AMCs are also uniquely qualified to undertake rigorous research to better understand the misalignments and misunderstandings found in studies like the Value survey. In fact, more than simply being capable, I think the public service missions of AMCs virtually obligate them to be leaders in this essential effort.

But they are not obligated to lead alone, nor would their solo leadership be compelling enough to bring all stakeholders to the table. We need corporate health benefit plans, for-profit health systems, and insurers — at a minimum — to help lead this effort.

If Messrs. Bezos, Buffett, and Dimon really want to drive major change in the U.S. health care delivery system, they should help convene value-focused dialogues, providing the kind of political and economic cover necessary to bring stakeholder groups into these conversations. And they shouldn’t stop there: They’ll have to remind everyone that these conversations aren’t only about cost containment — that “value” means more than just what we pay. (Or, as Buffett put it in one of his famous chairman’s letters, “Price is what you pay; value is what you get.”)

They should partner with providers, hospitals, and health systems to develop more-effective provider/hospital review systems and other methods of enhancing communication among parties in the care delivery process. They should seed pilot projects aimed at bridging the gaps in patients’, physicians’, and employers’ definitions of value. And being the smart, creative, bold people they are, they should help guide all stakeholders through the difficult compromises necessary to create a collective vision of a high-quality, patient-focused, cost-effective health care system.

That would truly be disruptive.



These 6 healthcare leaders say quality improvement is an organizationwide effort and a cultural imperative


Executive looking out window

Despite recent uncertainty about the government’s commitment to value-based care, healthcare organizations remain focused on efforts to improve quality, patient care and employee engagement.

In 2017 the Centers for Medicare & Medicaid Services cancelled mandatory bundled payment models for hip fractures and cardiac care and also asked providers for feedback on other value-based payment models.

But healthcare organizations seem committed to the initiatives they have already put in place to improve quality. Indeed, last year healthcare leaders shared their successes, challenges and lessons learned as they worked to improve quality and patient outcomes. We’ve rounded up the most memorable quotes from these healthcare thought leaders about quality, the importance of physician engagement and how to achieve a culture of patient safety.

Here are six of our favorite quotes from our interviews and industry news and event coverage over the past 12 months:

1. “We had to challenge our old paradigms. Physicians are instrumental in setting the tone, and unless the physicians believe we’re on the right path we don’t have the kind of alignment that will help us move forward.”

Gary Kaplan, M.D., chairman and CEO of Virginia Mason Health System, explained in a webinar this fall how the Seattle system improved patient safety using a patient-centered approach. Virginia Mason’s safety culture transformation began in 2001, Kaplan said, when system leaders realized that a physician-centered approach alone would not improve patient care.

2. “You need to start with the early adopters. You can’t start with folks who will fight you tooth and nail. You want to start with early successes and then evolve from there.”

Felipe Osorno, an executive administrator at Keck Medicine of the University of Southern California, spoke at the Institute for Healthcare Improvement’s annual quality forum about strategies to engage physicians in improvement initiatives. The secret was designing a program in which physicians were respected for their competency and skills, their opinions were valued, they had good relationships with their medical colleagues, they had a broader sense of meaning in their work and they had a voice in clinical operations and processes, he said.

3. “We really want to attract folks who believe at their core, not just intellectually but in their heart, that kindness can heal. … If we do it right the first time and we assess candidates based on the fit of the organization, ideally we will have more engaged employees who deliver care in a way that is patient-centered.”

Wanda Cole-Frieman, vice president of talent acquisition at Dignity Health, talked to FierceHealthcare this summer after the California system was named by an online job platform as the best place to interview in 2017. Among its techniques: It assesses candidates’ behavioral competencies for human kindness, compassion and the human experience.

4. “To create a true culture of safety and reliability we need to engage everyone, and it can only be driven when we have strong alignment. Everyone can play a role in safety.”

Gary Yates, M.D., a partner in strategic consulting at Press Ganey, explained in an interview that building and promoting a culture of safety at healthcare organizations is important to retain current staff members, but is also an especially effective recruiting tool for millennials, who will make up half of the workforce by the year 2020.

“People talk, and people ask about the culture inside different organizations,” Yates said. Putting the spotlight on safety and quality could “tip the scales” for young people.

5. “Our focus is safety, to fundamentally be a safe hospital. If we start there or if any hospital starts there, patient experience will take care of itself, quality metrics will take care of itself as will employee morale.”

FierceHealthcare caught up with Nicholas “Nico” R. Tejeda, CEO of The Hospitals of Providence Transmountain Campus in El Paso, Texas, at an American College of Healthcare Executives event. He talked about opening a new teaching hospital and establishing the culture of the organization from the beginning and with every hire.

There are no acceptable levels of errors, he said. And while it may be nearly impossible to achieve zero incidents, he still wants the organization he leads to strive for perfection.

6. “We don’t see quality as just a clinical goal. It’s an enterprisewide priority that encompasses customer service, compliance and wellness.”

A few years ago, Anthem decided to make a “rigorous” effort to boost the quality of its plans. And it’s demonstrating results, Anthem’s then-CEO Joseph Swedish said during the 2017 AHIP Institute & Expo. Now, more than half of the insurer’s Medicare Advantage enrollees reside in 4-star plans, compared to just 22% the year before.


Texas Health Resources utilizes work-from-home model to increase revenue cycle productivity


Whatever hours they’re at their best is when Texas Health Resources wants them to work, system says.

When Texas Health Resources hires new staff members to work in its revenue cycle department, it’s now required — for most functions, anyway — that they work virtually from home. Staff who have been there since before the virtual implementation have the choice, but many choose to go the route of the new hires. It’s a nice perk for the employees, but an even nicer one for the system, which has seen productivity increase significantly since taking this approach.

James Logsdon, THR’s vice president of revenue cycle operations and strategic revenue services, said the concept emerged in 2011 during the Super Bowl.

Dallas was the host city that year, and the big game took place in the midst of a rare ice storm. Logsdon came into work with the wind still whipping and noticed immediately that the office was like a ghost town, with few employees in sight. The system lost three to four days of productivity because people simply couldn’t make it into work, and thus a challenge was born: Turn revenue cycle operations 100 percent virtual within a year.

“It started out as a business continuity plan, but progressed into an initiative,” said Logsdon, recalling the event during the Healthcare Financial Management Association‘s annual ANI conference in Orlando. “It was a drive.”

It took longer than a year, and it may never reach 100 percent; some functions have to stay in-house, particularly with the jobs that involve direct patient interaction. But the effects have been noticeable. Employee satisfaction and morale are at an all-time high, and the turnover rate has been reduced substantially. The system used to lose revenue cycle employees to jobs that paid 10 or 15 cents an hour more, but no longer.

The linchpin of the program’s success is quality. It can’t budge an inch, and employees have to be held accountable.

“The metrics have to be award-winning,” said Logsdon. “You’ve got to set the expectation that this is a privilege. It’s something that could potentially be taken away. Basically, the message was, ‘Don’t let me down.'”

So far they haven’t, and part of the reason is the flexibility the virtual job affords them. Workers are allowed to set their own schedules as long as they put in the minimum eight hours. At whatever hours they’re at their best is when THR wants them to work.

Benefits aren’t just limited to reduced turnover and higher productivity, either. The system allows for better use of its real estate. Where there were cubicles packed tightly together like honeycomb bees, there are now classrooms, war rooms and revenue cycle training areas.

All that saves the system money, since it now uses its existing space for such purposes rather than expanding its footprint. New revenue cycle personnel are expected to work at least 90 days in the office while they undergo their training and education, but after that, they’re released to their virtual offices.

That’s not to say there aren’t challenges. Logsdon said that in some instances employees feel a sense of entitlement, resisting requests to return to the office when the need arises. There are also distractions that differ from the usual office distractions — children, neighbors, friends and family can sometimes intercede. To address this, THR conducts unannounced site visits to make sure everything’s copacetic.

The arrangement has created some new challenges for management, as they now have to ensure employees are using the right equipment and protocols and have an appropriately speedy internet connection. Few issues have arisen.

“Productivity is a topic that always comes up,” said Logsdon. “The requirement for employees, in writing, is to increase productivity by 5 percent. They have no problem hitting it. It’s amazing what you can pull out of people when they’re motivated by the right reasons.”

Humility is the New Smart: Are You Ready?


Humility is the New Smart

SMART used to be a quantity game. “I know more than you. I get more things right.” But Ed Hess and Katherine Ludwig say that in the new Smart Machine Age, that’s losing game. The new smart is about quality. Specifically, the quality of your thinking, your listening, and your relating and collaborative skills.

Are you ready?

The Smart Machine Age (SMA) will revolutionize how most of us live and work. In Humility is the New Smart, the authors state that “smart technologies will become ubiquitous, invading and changing many aspects of our professional and personal lives and in many ways challenging our fundamental beliefs about success, opportunity, and the American Dream.” This means that the “number and types of available jobs and required skills will turn our lives and our children’s lives upside down.”

New skills will be needed. Uniquely human skills. Those skills, while uniquely human, are not what we are typically trained to do and require a deal of messy personal development. We will need to become better thinkers, listeners, relators, and collaborators, while working to overcome our culture of obsessive individualism in order to thrive in the SMA. Humility is the mindset that will make all of this possible.

Most of today’s adults have had no formal training in how to think, how to listen, how to learn and experiment through inquiry, how to emotionally engage, how to manage emotions, how to collaborate, or how to embrace mistakes as learning opportunities.

In short, say the authors, we need to acquire and continually develop four fundamental NewSmart behaviors:

Quieting Ego

Quieting Ego has always been the challenge for us humans. As they observe, “Even if we don’t consider ourselves part of the ‘big me’ cultural phenomenon, for many of us to feel good about ourselves we have to constantly be ‘right,’ self-enhance, self-promote, and conceal our weaknesses, all of which drive ego defensiveness and failure intolerance that impedes higher-level thinking and relating.” This tendency negatively affects our behavior, thinking, and ability to relate to and engage with others.

Managing Self—Thinking and Emotions

We need to get above ourselves to see ourselves impartially. We all struggle “to self-regulate our basic humanity—our biases, fears, insecurities, and natural fight-flee-or-freeze response to stress and anxiety.” We need to be willing to treat all of our “beliefs (not values) as hypotheses subject to stress tests and modification by better data.”

Negative emotions cause narrow-mindedness. Positive emotions on the other hand, have been scientifically linked to “broader attention, open-mindedness, deeper focus, and more flexible thinking, all of which underlie creativity and innovative thinking.”

Reflective Listening

Because we are limited by our own thinking, we need to listen to others to “open our minds and, push past our biases and mental models, and mitigate self-absorption in order to collaborate and build better relationships.” The problem is “we’re just too wired to confirm what we already believe, and we feel too comfortable having a cohesive simple story of how our world works.” Listening to others helps to quiet our ego.


To create these new behaviors and mindsets, it should become obvious that we need to enlist the help of others. “We can’t think, innovate, or relate at our best alone.” As Barbara Fredrickson observed, “nobody reaches his or her full potential in isolation.” Jane Dutton out it this way: “It seems to be another fact that no man can come to know himself except as the outcome of disclosing himself to another.”

The NewSmart Organization

Optimal human performance in the SMA will require an emphasis on the emotional aspects of critical thinking, creativity, innovation and engaging with others. “The work environment must be designed to reduce fears, insecurities, and other negative emotions.

To do this it means “providing people a feeling of being respected, held in positive regard, and listened to. It means creating opportunities for people to connect and build trust. “It means allocating time and designing work environments that bring people together to relate about nonwork matters.” Finally, it means getting to know employees and helping them to get the “right training or opportunities to develop and provide feedback.”

The NewSmart organization needs to be a safe place to learn. “Feeling safe means that you feel that your boss your employer, and your colleagues will do you no harm as you try to learn.”

The New Smart

Treat Employees Right So They Treat Customers Right


Isadore Sharp,  Founder And Chairman, Four Seasons Hotels And Resorts (Photographer: Bryan Mills for Four Seasons)

Isadore Sharp, Founder And Chairman, Four Seasons Hotels And Resorts

Starting from a modest offshoot of his family’s construction business (“The Four Seasons Motor Hotel,” if you can believe that), founder and chairman Isadore Sharp has built one of the great brands and organizations in the hospitality industry, the privately-held Four Seasons Hotels and Resorts, with 93 highly-rated luxury hotels and resorts under management worldwide.

Most impressive to me is that the Four Seasons organization  has been built in alignment with Mr. Sharp’s longstanding commitment to The Golden Rule, to applying this principle of fairness to all of the entities involved in creating their hospitality experience; to quote the Four Seasons corporate framework, “In all our interactions with our guests, customers, business associates and colleagues, we seek to deal with others as we would have them deal with us.”  The success of this approach in employee retention –Four Seasons has one of the lowest turnover rates in the industry–and engagement–Four Seasons has been ranked in the “100 Best Places To Work” for 18 years straight–is evident, and Mr. Sharp also credits this philosophy with allowing Four Seasons to provide what he says is the single most important factor in the success of his company: a superior level of customer service.

IU Health Has a Different Leader, Different Strategy



IU Health’s new top boss says the ability to withstand constant change will be a mark of success for top health systems.

Only one hospital made all four recent top hospitals lists


Photo of St David's Medical Center in Austin, Texas from <a href="https://www.facebook.com/stdavidsmedicalcenter/timeline">Facebook</a>