Monday, May 5, 2014

"VALUE" IN HOLLYWOOD - Notes from the Pediatric Orthopaedic Society 2014 (part 1)

I recently traveled to Hollywood for the annual meeting of the Pediatric Orthopaedic Society of North America (POSNA).  I am always bemused by LA and especially Hollywood, packed as it is with an odd mix of tourists and denizens, the former trying to snap photos of Marilyn Monroe’s footprints, the latter trying to shill lurid stories about the stars’ dwellings and demises.

The meeting was held in the same facility that hosts the Oscars, and as expected, they did their best to schmaltz it up, complete with a Red Carpet Banquet, which I missed.  It would have been fun to see what some of my colleagues came up with as Hollywood formal.

On the serious side, amidst the usual presentations about hip reconstruction and clubfoot (to operate or not, that is always the question), there were some curious trends that I noticed in the overall thought process of the group, mostly change for the better although some of it remains to be seen.  The watch cry for the whole meeting was “Value”, which is the newest in a long line of buzzwords in the medical community.  In past the issue has always been to define the word in a practical manner so that it can be measured, duplicated (and I guess hopefully rewarded).  The working definition that interlaced a lot of the conversation was the quasi-mathematical expression [Value=Outcome/Cost].  So simple – plug in the numbers and you will have the secret value score.  The problem remains as always: what are the numbers to plug in?

Cost, one would think, is an easy variable to define.  All things have a finite price after all, and there must be some way to find and report that price.  But as we all know, medical economics defies even the simplest logic.  In fact any medical occurrence has multiple prices.  There is the price for the actual treatment (brace or implant or what have you), the price for the treating doctor’s visit, the price for any hospital service, the price for anesthesia, and so on.  About the only one of those that is easy to obtain is the charge of the treating physician, and even that is complicated by the fact that the actual number may have little or nothing to do with the actual fee that a patient or an insurer pays.  Don’t even try looking for hospital or implant costs – that way lies madness.

What about outcome?  By definition, this is a non-numerical factor which wiser heads than mine have been trying to arithmetize for decades.  As such, there are complex surveys and instruments which are supposed to come up with a useable score to plug into this kind of formula.  Although some of these may work in some settings (the Harris Hip Score is elegant for simple arthritis of the hip but not so good for hip impingement), these tools are bulky and hard to implement.

The emphasis at POSNA was on bolstering awareness of the need to understand cost and outcome, so that a value can be derived.  The insurers and the government conflate value with cost alone, but the mere cutting of costs may not enhance the value of anything.  Ultimately, the goal is to bolster the value to such a degree that it overrides any effect that the cost may have.

An excellent point made was that value must be determined in communication with the patient and family, not just by some measurements on an x-ray.  Even if a hip implant lasts for 25 years, it is still not valuable if the patient is in constant pain for every day of that span.

So, finally and at long last, surgeons (and I presume all doctors) will be forced to speak to their patients before, during and after their care.  They will need to go beyond the superficial questions (“Any pain?”) and delve into complex interactions like “How has this affected your life?”, “Did the surgery match your expectations?” or the all-important “Are you satisfied with your care?”  Although these factors will be hard to quantify, they are the true measurements of value.