Competition on Outcomes and Physician Leadership Are Not Enough to Reform Health Care

Abstract

SOCIETY FLIES BLIND WHEN IT COMES TO HEALTH CARE. The value of treatments to patients, in particular with respect to health gain, is not routinely measured. As a result, reforms focus less on improving health and value to patients and more on cost minimization; consequently, such reforms are led by administrators, not physicians. Physicians are disgruntled and disenfranchised, and perversities result such as, in the United States, cost shifting and other forms of dysfunctional competition. The way forward is for physicians to seize the initiative, take as their goal improved value of care to patients, organize medical practice around medical conditions and care cycles, and measure riskadjusted outcomes and costs, all within a competitive health system. Positive-sum competition for value to patients will result that only physicians can deliver. Tinkering with financial incentives in the system will never be enough. In a reduced form, this is the main argument advanced by Porter and Teisberg for reforming and improving the US health care system. However, there are important similarities in England’s National Health Service (NHS). While reducing overall cost growth is not a problem due to the (relatively) large real-term increases in the global fixed budget over the last 7 years, health reforms in England have been in the main led by politicians and implemented by managers, with the physician community largely on the sidelines, antagonized or marginalized. Measuring risk-adjusted clinical outcomes is not widely implemented, prompted by public outrage (for example, following well-publicized failures in cardiac surgery) as much as by professional leadership. The financial bottom line, rather than health gain, tends to drive local reconfigurations in service. To improve the health care system, physicians should take a firm lead: a large portion of the activities most likely to have an impact on improving outcomes and quality are embedded in the care setting provided by physicians interacting directly with patients. However, it is unlikely that physicians will rise to the leadership needed, at least in the NHS, and some of the “false solutions” rejected by Porter and Teisberg are necessary and worthwhile candidates for future reforms. In this Commentary, we explain why, and describe how some of these “false solutions” are being used to reform the NHS to achieve better value for patients.