Transcript A crucial concept for health reform in South Africa

THE VALUE AGENDA:
A CRUCIAL CONCEPT
FOR HEALTH REFORM
IN SOUTH AFRICA
Michael Thiede
Preamble: Entangled in South Africa
Outline
• Some thoughts on VALUE
• The VALUE AGENDA
• VALUE CREATION
• An inconvenient truth
• Health reform in South Africa
• Objectives
• Rehabilitating the VALUE AGENDA
• Towards a systemic VALUE AGENDA
• Barriers
• Patient focus from a health systems perspective
• Mastering health reform in South Africa
• Outlook
Value – the first 2,500 years
Value in health and health care:
What (else) is new?
• Value in health care and health systems as a reference point in 20th
century health policy debates
• “[I]f we apply humane values to such concrete problems as health care costs, we will both
solve the economic problem and enrich our lives … as a community”
J. McCabe, CEO of Blue Cross/ Blue Shield, MI (October 1984).
• “The individualism of the West seems to apply less to patients than to physicians … .”
D. Light (1985) on patient value in the German SHI system
• In other disguises, e.g. as Efficiency Rule (Wirtschaftlichkeitsgebot) in
the German SHI system [health system level] or simply as target
dimension in health economic discourse
Light, D. (1985) Values and structure in the German health care systems. Milbank Memorial Fund Quarterly, 63(4), pp. 615647.
McCabe, J. (1985) Human values. The evolution of the health care system. Vital Speeches of the Day, 51(10), pp. 303-306.
The VALUE AGENDA
• Organizing around patients’ medical condition rather than
physicians’ medical specialty
• Measuring outcomes and costs (for each patient)
• Developing “bundled prices”
• Integrating care across separate facilities
• Expanding geographic reach
• Building enabling IT platform
Porter, M. & Lee, T. (2013) The strategy that will fix health care. Harvard Business Review, 91(10), pp. 5070.
VALUE CREATION: Two Case Studies
• Mayo Clinic  “High-value Practice”
• Alignment
• Discovery
• Managed Diffusion
• Measurement
• West German Headache Centre (WGHC)
• Innovation
• Integration
• Measurement
Swensen, S.J., Dilling, J.A., Harper, C.M., Noseworthy, J. (2012) The Mayo Clinic‘s Value Creation
System, American Journal of Medical Quality 27(1): 58-65.
Porter, M. & Guth, C. (2012) Redefining German Health Care, Heidelberg: Springer.
Why the South African health reform
challenges are different …
• Economic versus social goals
• Role of corporations in society
• Business compliance?
• Complexity of transforming social “plus” individual objectives into
business opportunities
• Heterogeneity
Inconvenient truth
• There is no reason to assume that value defined and created at the
provider level will translate into collective value at the health system
or societal level.
• There may even be a social dilemma.
• The VALUE AGENDA may not help prevent regulation.
Principles of the NHI reform in South Africa
• Universal Health Coverage
• Access
• Equity
• Effectiveness
• Efficiency
• Appropriateness
 Whither VALUE?
Rehabilitating VALUE
• VALUE and the communicative contract
• VALUE is embedded in the context of the South African
lifeworld
• Cultural traditions of shared social meanings
• “Intersubjectively shared … certitudes”
Institutions of open and responsible communication
How do we ensure that the future South African health system
embraces VALUE?
Towards a systemic VALUE AGENDA
• Governance (paradigm)
• Institutionalization
• Information and transparency
• Operationalization of efficiency
• Quality
1. Governance paradigm
• Governance as a conceptual representation of co-ordination of
social systems
• Governance as accountability
• Association of governance principles with management principles
• “A good paradigm … limits excesses of human nature and ensures
an atmosphere of happiness and productivity by promoting reason
and dignity” (Nayef Al-Rodhan)
Dubnick MJ & Frederickson HG (eds.) (2010) Accountable Governance: Problems and promises.
Armonk, NY: M.E. Sharpe.
2. Institutional framework
• Accountability
• Coherent decision-making structures
• Interactive governance
• Co-production
• Co-allocation
• Co-management
• Co-evolution
• Stakeholder participation
Kooiman, J. (1999) Social-political governance: Overview, reflections and design. Public Management, 1(1), pp. 67-92.
3. Information and transparency
• Participation and communicative action
• Information systems, big data
• Health services research  analyzing the “last mile”
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Service data
(Patient-reported) Outcome data
Cost data
Data on preferences (e.g. via DCE)
Etc.
[Role of HSR for SHI funds in Europe]
Ryan, M., Gerard, K. & Amaya-Amaya, M. (eds.)(2007) Using discrete choice experiments to value health and health
care. Dordrecht: Springer.
Roski, J., Bo-Linn, G. & Andrews, T. (2014) Creating value in health care through big data: Opportunities and policy
implications. Health Affairs 33.7, pp. 1115-22.
4. Operationalization of efficiency
• Provider reimbursement
• E.g. case-based (hospital) reimbursement (linked to quality)
• E.g. P4P
• Pricing
• Principles
• Institutionalization (governance!)
• Contracting
5. Quality
• Quality management (across levels of care)
• Evidence-based care, pathways
• Role of high-quality (routine) service data
• Benchmarking as a tool of organizational development
 Benchmarking networks?
Szecsenyi, J., Campbell, S., Broge, B. et al. (2011) Effectiveness of a quality-improvement program in improving
management of primary care practices. CMAJ, 183: E1326-E1333.
Barriers
• Self-reinforcement and path dependence (“history matters”)
• Organizational, e.g. fragmentation through specialization
• Technological (including infrastructural)
• Institutional
• Political rigidities and lack of communication “across boundaries”
• Entrepreneurial spirit of industry  thinking in organizational units
rather than systemic
• Pitfalls of incrementalism
• “Learning disabilities” within the NHI process:
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Commitment trap
Fixation of events
Delusion of learning from experience
Parable of the boiling frog
• Skills and capacity
Patient focus from a health system
perspective
• Address the patients’/population’s system needs
 embrace health services research
• Get the incentives right
 develop smart payment systems
• “Integrate” care across (sub-)systems
 evidence-based and systematic/coordinated
(role of information systems and technology)
• Build up a multi-skilled workforce that supports patient
empowerment
 continuous learning, measurement and feedback
• Substitute process targets by outcome targets (at all levels)
Mastering health reform in South Africa I
• Ensure inclusive (process) governance
• Accountability
• Transparency
• Communication
• Consider access first
• Re-think institutions! Change management
• Acknowledge requirements of a primary care centred system
• Coordination (including social care, home care, ambulances, specialist care)
• Pathways (evidence!)
Mastering health reform in South Africa II
• Embrace information systems and think “app”
• Any future telematics infrastructure in South Africa must be social
• Quality management
• Clinical pathways, outcome measurement
• Establish best practice models (benchmarking)
• Always think financing
• Smart payer(s), contracting, reimbursement models
• Establish principles rather than inflexible solutions
• Be serious about putting people first
Outlook
• Systemic VALUE AGENDA can support reform process
• Limits to the operationalization of VALUE
• Competition based on care, implying that the provider does
well if the patient does well
• Evidence-based design requires consistent assessment of
patient benefit and strict focus on quality benchmarks
• Innovation  VALUE is not a static concept:
What will be people’s health needs and wants in 2030?
THANK YOU