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.
Dear Dr. Mankin, This is a post unrelated to Hollywood, but I was not sure how to contact you, so am trying this! I appreciate your blog, and was particularly drawn to an older post about a young artist Ian Barrie. I am hoping you can help me reach Mr. Barrie, as I would be greatly interested in learning more about his work, and sharing it with others through my magazine Scoliosis Quarterly. If you might be able to connect me with him, it would be greatly appreciated! Sincere thanks! Maureen Heintz scoliosisquarterlyATgmailDOTcom
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