Michael Thiede

• 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 in health care and health systems as a reference point in 20 th 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. 615-
647.
McCabe, J. (1985) Human values. The evolution of the health care system. Vital Speeches of the Day , 51(10), pp. 303-306.

• 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. 50-
70.

•
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.

•
Economic versus social goals
•
Role of corporations in society
• Business compliance?
• Complexity of transforming social “plus” individual objectives into business opportunities
•
Heterogeneity

•
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.

• Universal Health Coverage
• Access
• Equity
• Effectiveness
• Efficiency
• Appropriateness
 Whither 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?

• Governance (paradigm)
• Institutionalization
• Information and transparency
• Operationalization of efficiency
• Quality

•
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.

• 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.

• Participation and communicative action
• Information systems, big data
• Health services research  analyzing the “last mile”
•
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.

• Provider reimbursement
•
E.g. case-based (hospital) reimbursement (linked to quality)
•
E.g. P4P
• Pricing
•
Principles
•
Institutionalization (governance!)
• Contracting

• 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.

• 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:
• Commitment trap
• Fixation of events
• Delusion of learning from experience
• Parable of the boiling frog
• Skills and capacity

• 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)

• 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!)

• 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

• 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?