Dr. Randall Lee on creating a value-based care framework


“As we increase spending, we know there are good data out there that we haven't seen reflective improvement in outcomes or decreasing complications when we treat our patients,” says Randall A. Lee, MD.

In this video, Randall A. Lee, MD, discusses the background behind the European Urology Focus study, “Transition to Value-based Healthcare: Development, Implementation, and Results of an Optimal Surgical Care Framework at a National Cancer Institute–designated Comprehensive Cancer Center.” Lee is as an assistant professor in the Department of Urology at Fox Chase Cancer Center in Philadelphia, Pennsylvania, and a member of the Fox Chase-Temple Urologic Institute.


Please describe the background for this study and discuss its findings.

I think when we look at how we came up with the idea for this initiative, I think it's really important to understand how health care is essentially delivered in the US. There are a bunch of different payment models out there, but a majority of the systems are a fee-for-service system. [There are] other systems out there that look to factor in value—bundled payments and things like that—but for a majority of them, it's a fee-for-service system. And the problem with that is that you essentially are getting paid for a service that you provided; basically, you produce, and you get paid. Administration will tend to increase spending to reflexively see an increase in production. The problem is that we have increased spending exponentially over the past decade, to the point where health care spending is about 20% of our GDP. As we increase spending, we know there are good data out there that we haven't seen reflective improvement in outcomes or decreasing complications when we treat our patients. Back in 2006, Michael E. Porter and Elizabeth Olmsted Teisberg came out with a publication about how we can change this and shift toward what's called a value-based health care delivery system. The real key is how they defined value. If you look at this like a fraction, they defined value as the outcomes that the patient gets over the cost or spending that is required to reach those outcomes. They found that a lot of systems, especially in these fee-for-service systems, it was more of a cost-cutting methodology, essentially, to increase value in that aspect. And when we look at outcomes, it's really how do we define which outcomes are associated with value? And I think that is the key, in a lot of the literature that's out there is that everyone is working toward defining those metrics, and defining what truly is value. At our institution, under the leadership of Robert G. Uzzo, MD, MBA, FACS, our CEO, and James L. Helstrom, MD, MBA, our CMO, we really created this initiative to look at value and how we can think differently, because the way we're spending in health care is not sustainable. At our institution, we follow the NSQIP database, which is a collection of postoperative and perioperative outcomes across almost 500 institutions in the country. A lot of quality improvement studies come from that. And when we were looking as we were analyzing our NSQIP data, [we asked], is there a way to select some of these variables to create metrics that are associated with value? And that's what we did; we got together and came up with 6 core measures that we associated with value: 30-day return to the operating room, 30-day readmission rates, surgical site infections, the appropriate use of antibiotics, the appropriate use of transfusions, and accidental punctures or lacerations that happened during these procedures. And we really looked to see if we could apply that to all the procedures at our institution. Interestingly, we know that when you do something like this, it takes a cultural change. I mean, you're taking something where providers have practiced a certain way and are used to a certain way of how administration and thought leaders respond to [along the lines of], "See this many patients, and we expect you to produce that much." And so we're asking for a complete cultural change on how we do things. And I think how we implemented our framework is just as impressive as what the framework was. We essentially broke this up into 2 different metrics of how we define value, one with the 6 core metrics that we had talked about just now. And the other is that we understood that each procedure type and each specialty has their own special nuances. So we actually created procedure-specific metrics as well. And in doing that, we invited surgeons and thought leaders in our institution, as a part of the development process, so they actually have a say in what we were building. And I think that is key. And we describe that as a top-down, which is our leaders in in the hospital coming up with their rubric, and the bottom-up approach in which we invited the boots on the ground to have a role in this. I think when providers have a say, and providers feel like what they're saying is being heard, it goes a long way in having that framework succeed. They're almost invested in it.

This transcription was edited for clarity.

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