Health Care Insider: Making the Evolution of Health Care About the PatientJul 3, 2014
Driven by advances in science and technology, health care systems are changing and evolving. But are all of these changes necessary, and, more importantly, do they provide what’s best for the patient? How does cost factor into this change? Partners Healthcare System is the largest health care provider in Massachusetts, and with several Harvard Medical School-affiliated hospitals in the Boston area has emerged as a leader in academic health care. University of Utah Health Care CEO Dr. Vivian Lee sits down with the Chief Clinical Officer of Partners Healthcare, Dr. Gregg Meyer, to discuss sweeping changes in health care.
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Vivian: Well, today I'd like to welcome to the show, Gregg Meyer.
Dr. Gregg Meyer: Thank you for having me.
Vivian: Dr. Gregg Meyer is the Chief Clinical Officer of Partner's Healthcare System in Boston which is a joint effort between the Massachusetts General Hospital and the Brigham and Women's Hospital. And he is overall responsible for direction, operations, and management of the system aspects of healthcare throughout that system, so welcome to the show.
Dr. Gregg Meyer: Thanks. It's really terrific to be here.
Vivian: Gregg is somebody that I have known for almost 30 years and followed your career with great admiration. You've been just such a thought leader in healthcare and in the transformation of healthcare, and you just came back to Boston to take on this leading role. Tell us a little bit about your thinking for how the Partner's Healthcare System can really help lead the transformation of academic healthcare.
Dr. Gregg Meyer: I think at Partner's we're incredibly blessed by having two of the world's leading academic medical centers at our heart. We've always had this terrific opportunity to take care of the sickest of the sick patients, do cutting edge research, and to teach the best and brightest, and serve our communities. But there is a lot of change going on in healthcare right now and what we need to do is we need to take all of the good things that we've been able to do with our system, but to retool them in a way that meets an emerging need to improve the value in healthcare, to try to be able to ensure that we give patients the greatest possible outcomes, but provide care more efficiently, something we never focused on before.
And I came back because that's an incredible challenge for us, but boy, to work in that system is just a huge opportunity. And like the Univeresity of Utah, one of our aims is not just to be able to do well as an academic health system and serve our local patients. We want to be a national model.
Vivian: Well, you really epitomize, I think, the biggest challenges that academic health centers are facing. Well, first the fact that we attract some of the sickest of the sick, but also the fact that we're training and we might take a little bit longer because we have medical students in the room or we have residents in the room. And do you think our society is willing to pay a premium for those extra costs?
Dr. Gregg Meyer: Yeah, let's face it. We're expensive places and we're expensive places partly because of the reasons you said, because we provide special services that aren't available elsewhere. For example, burns units, really expensive to run and keep that up.
Vivian: Right, absolutely.
Dr. Gregg Meyer: But boy the community needs it.
Dr. Gregg Meyer: We have our teaching programs. We have our research programs. But in addition to that we haven't always been the best stewards with resources either. And so to some extent we have this tremendous need to focus not just on the great care that we can provide, but we need to be more responsible with our resources. And in the end, I think that as academic systems we need to show people how to do that and show the community that we can really deliver value because now the patients are not just asking, wow, is the Univeresity of Utah or is Brigham Women's, or the Mass General and all, the best place for me to go? What is the best place where I can go and I can afford it?
Dr. Gregg Meyer: We need to address that challenge.
Vivian: Yeah, so this value theme is really just pervading all the healthcare and its core to the transformation. And we have been thinking here at the University of Utah as value being defined as quality plus service divided by cost where we include that patient satisfaction piece and service piece. You introduced a new element to that and just tell us about your thinking about the definition of value.
Dr. Gregg Meyer: Yeah, and I think that you've got it mostly right, but I think there is an additional element there. And if we go back to our colleagues and these students of medicine, look at their definition of quality. And they will say that quality includes safety, effectiveness, efficiency, equity, timeliness, and patient centeredness. And buried in there somewhere is the notion that you ought to get the care that you need, but I think we need to pull it out more explicitly. So my value equation differs a little bit.
Dr. Gregg Meyer: And so what I would define as value is I'd say value equals appropriateness times outcomes and service divided by costs. Let me explain.
Dr. Gregg Meyer: The appropriateness piece means that you are getting the care that you need. We could, in fact, deliver services in a very patient centered way with what look like good outcomes and do it for a relatively low cost, but if the patient didn't need it to start with, that's not good value.
Vivian: Do you think we're doing that a lot in healthcare, that we are providing care that may not be needed?
Dr. Gregg Meyer: I think if you look nationally, for example, the Dartmouth Atlas and look at the variation in healthcare utilization across the country, it's quite clear that yeah, there is some of that going on. One of the things that we're doing at Partner's is we're tackling that head on. We're actually starting to implement a system, procedure order entry which actually asks providers to document the appropriateness of that procedure going forward. In addition to that, we bring in the patient centered element and that is to introduce shared decision making. So not only is this patient the right patient for that procedure based on the technical aspects of, for example, their arthritis or their heart disease, but is this the right procedure for that patient, meeting their own needs and expectations?
So that combination of looking at appropriateness from a provider perspective and looking at the right kind of decision from the patient perspective, I think that gets us to that appropriateness piece. And I would argue that if we don't focus on that and just focus more narrowly on outcomes divided by costs, we're going to miss something. And I believe that some of the real value that an academic health system, be it in Boston or in Salt Lake City, that we can deliver to our community is that we can really be very fastidious, and really focus on that appropriateness in a way that no one else can.
Vivian: So why do you think that some of this care right now that's being provided is not appropriate? What's driving that? Why would that be happening?
Dr. Gregg Meyer: I think there are multiple drivers. I think part of it is unless you kind of break it down a little bit, and I would say that there are societal patient and provider aspects that . . . And my former colleagues at Dartmouth, that Jack Weinberg and others have written extensively about, this whole notion of preference sensitive care. From a societal standpoint that you can't turn on the television set or listen to the radio without hearing an advertisement that talks about the fact that you need to get this procedure done and how much we're going to do it better than I heard on the way over here.
Vivian: A new drug.
Dr. Gregg Meyer: This morning I heard a cancer center ad and one about a total joint replacement. From a patient perspective, one of the things that really, I think, is an American characteristic for better or for worse is we want things and we want things now.
Vivian: And we want the best.
Dr. Gregg Meyer: And we want the best.
Vivian: Yeah, that's right.
Dr. Gregg Meyer: And so from a patient perspective is, boy, if my knee finally gets to the point where it's bothering me and I can't do that 5K race I want to do, I want to get my knee replaced right away. And I want to get it done by the surgeon of my choice. From the provider perspective in many ways, we probably haven't been introspective enough.
Dr. Gregg Meyer: And I think that one of the most powerful tools that we have is transparency and I know that you've leveraged it here on your website. The Univeresity of Utah, we do a lot of it. Partner's Healthcare, we do a lot of it. Dartmouth Med is looking at ourselves, looking at our own data and saying, "Boy, how do we match up with benchmarks from around the country in terms of how many procedures that we're doing? Are we potentially doing things that aren't needed? Are we imaging too much?" And one of the things that I always remind myself as a primary care doctor is, there is no satiety to the American's public desire to see what the inside of their body looks like. Everybody loves the notion that I can get an imagine done.
Vivian: As a radiologist I can really attest to that.
Dr. Gregg Meyer: Everyone loves that. I said that on purpose. Everyone loves that and the reality is that there is a lot of imaging that probably is not necessary at this point. And boy, there is the aspect to it, it costs a lot of money and it takes away time.
Vivian: And sometimes you see things that don't even matter and it gets you worried for nothing.
Dr. Gregg Meyer: Exactly.
Dr. Gregg Meyer: But there are other costs there.
Dr. Gregg Meyer: And those other costs are there are the direct physical harm costs and that include radiation exposure. And more importantly they are the costs of all the false positives of the things that really aren't important, but that we end up putting patients through invasive procedures or even a larger category. And those are things where we don't even know what they mean.
Dr. Gregg Meyer: And because of that we go. So I think there are a lot of drivers for perhaps, for this inappropriate care. In the end though it's not going to be tackled by one. So think about this, societal aspect of it, the patient aspect of it, and the provider aspect to it. And I think bringing those together is going to help us maximize that piece of the value equation.
Vivian: Yeah, there's so much change going on. And most of us who grew up in the healthcare system were trained certain way and now we really are being asked to completely rethink and re-evaluate the way that we practice. And how do you as the Chief Clinical Officer at Partner's with thousands and thousands of physicians under your purview, how do manage that change? How do you help the providers, the doctors, the nurses, everybody get through this period and still feel good about what they do every day?
Dr. Gregg Meyer: And no, really, that's our work. That is our work every single day. And I do think that one of the things that I always find incredibly disturbing is when I speak to colleagues and I ask them, how many of you would recommend to your children not to become a physician? And when I hear people say, "I wouldn't recommend that anymore. It's changed too much." It's heartbreaking for me because what other job are you ever going to have where you have the opportunity to do cutting edge science, to interact with people at the most intimate levels, to experience humanity up-close and personal. It is a privilege every single day.
Vivian: It is.
Dr. Gregg Meyer: And I think what we need to do as leaders through this change, we need to do two things. I think number one is people get too in touch with, yeah, it's really scary, but it's really exciting.
Dr. Gregg Meyer: And there are many things that many of us dreamed about and thought about in medical school, the way health systems ought to work, and how we ought to focus on health and not just healthcare delivery.
Dr. Gregg Meyer: That suddenly the piece is starting to fall into place that maybe we're going to be able to do that.
Vivian: Yeah, that's right.
Dr. Gregg Meyer: So I think the first thing is to get people really excited about it. And I think that the second thing is to give people hope.
Dr. Gregg Meyer: And say, we can do this. But yeah, it's going to be a big challenge and it means that there are going to be changes in the way that we see patients, and the change is the way the patients use the healthcare system, and paves the way that we that run healthcare systems think about our role in the community, but in the end there is a way to get through this and we'll get through it together. So I think those two things, getting people excited and giving them hope. That's what our job is.
Vivian: Wow, Dr. Gregg Meyer, we are so lucky to have you as a leader in healthcare and leading us to this very, very bright future ahead. Thank you so much for joining us today.
Dr. Gregg Meyer: Thank you Vivian.
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