A New Lens.

Mariam Fofana, M.D. 

Resident in Emergency Medicine

Brigham and Women's Hospital/Massachusetts General Hospital 

PGY 4

06/08/2021

I came to the VBHD course as a skeptic. I consider health to be a public good and was wary of treating it as a business/industry like any other. Although the course takes a business school approach to examining specific healthcare delivery models, I very much appreciated the focus on value for patients. The concept of value as articulated in the course was new to me and I found it very helpful in framing the challenges encountered by healthcare systems and developing solutions. 

It is also very helpful to understand how to speak the language of business to convey ideas to certain stakeholders such as executives and funders. My primary career interest is in research and I don’t necessarily anticipate being involved in major healthcare transformation efforts, but I also have a significant interest in global health, and thinking about value as part of outcome assessment of interventions could help make healthcare more accessible and more equitable. The course has given me a new lens through which to consider how we deliver care and will likely prompt me to be more critical of some of the practices that we take for granted, or the systems that we think immutable.

Improving Quality and Value in Healthcare Delivery.

Matthew Joseph Best, M.D. 

Fellow in Orthopaedic Sports Medicine

Massachusetts General Hospital 

PGY 6

06/09/2021

Matthew Joseph Best, M.D. 

The value based healthcare delivery course allowed me to understand important concepts of the providing high quality medical care by improving outcomes and decreasing costs. The principles emphasized in this course will be important in various areas of my future career including my clinical practice, research groups, and in leadership positions. 

An understanding of how to improve value, accurately track outcomes, reduce costs, and provide high quality medical care are vital aspects of physician education and can benefit trainees from all medical disciplines.

Currently, I am utilizing some of the skills learned from this course in multiple research projects to accurately assess and measure costs and reduce cost variability in different domains of orthopedics. These themes can help to ultimately reduce healthcare costs and improve overall value. Additionally, I plan to use these skills in future clinical and research based leadership roles.

COE Healthcare Policy Course Through HBS

Martina Mustroph, M.D., Ph.D. 

Resident in Neurosurgery 

Brigham and Women's Hospital 

PGY 4

06/08/2021

I enrolled in this course at the recommendation of my coresidents who had taken it last year. In particular, they had stressed that for trainees to have access to some of this country’s experts in healthcare policy is one of the many benefits of training at an academic medical center with affiliated professional schools.

The course was held over zoom, and in my opinion successfully so. I particularly got a lot out of the daily evening hour-long small group discussions, in which 4 of my peers and I would be in an individual zoom room. We would complete the guiding questions pertaining to the day’s reading, but we also informally exchanged our experiences of training in different departments currently or (for fellows) in the past for residency. For instance, a fellow in a related specialty I have worked with closely for the past year spoke candidly about his residency experience as it compares to his current institution.

For me, the course was an excellent way to take a step back and look at the broader healthcare system in the U.S. and abroad. I think this is sometimes hard to remember to do while immersed in training. The course has given me a conceptual framework and vocabulary for assessing healthcare delivery. I am looking forward to my thinking about healthcare being less myopic.

A Valuable Perspective.

Laura Nicholson, M.D. 

Resident in Internal Medicine/Primary Care

Brigham and Women's Hospital 

PGY 3

06/09/2021

The Value-Based Healthcare Delivery course was a valuable educational experience and provided a unique opportunity to engage in discussions of healthcare payment and policy during residency. After three years of residency focused on learning clinical skills, this course offered an important systems-perspective that will inform how I think about the systems I deliver clinical care in the future. One of the most unique aspects of the course was the chance to engage with residents from different programs and levels of training. 

As an internal medicine resident, I do not often enter discussions with surgeons, emergency medicine, or radiology residents around these type of topics, and I found this to be a great learning opportunity. The case-based discussions allowed for a deep engagement with the various principles we discussed; they offered insights into payment systems and hospital programs that are different from those I have encountered as a trainee. The case discussion related to strategies hospitals have taken to address social determinants of health at both the individual and population level were especially informative. As an internal medicine resident going into primary care and hospitalist medicine, I am eager to apply these principles and ideas from this course to my future career as a generalist.

A Valuable Foundation.

Kelly Marie Scheuring, M.D. 

Resident in Internal Medicine and Primary Care

Brigham and Women's Hospital/Atrius Health 

PGY 2

05/26/2021

Kelly M. Schuering, MD

Participating in the Value-Based Health Care Delivery Course helped me to further develop the skillset I will continue using to advocate for higher value care for the medically complex and socially vulnerable in society. Despite trials of many unique approaches within complex care over the past decade, providing consistent value remains a major challenge. Through case studies of successful health care institutions, the course expanded my understanding of integrated practice units, outcomes measurement, time-driven activity-based costing, culture change, and expanding a care network, all of which are critical tools to increase value. The course also introduced me to like-minded trainees across MGB that I hope to continue to work with in the future, not to mention exposure to world-class leaders in business!

Though my focus has been primarily clinical to date, I know my desire to improve the flawed systems that I see failing patients will inevitably lead to administrative roles in the future. This course has helped prepare me to be a more effective agent in change in building a more efficient, but equitable health care system throughout my medical career as a primary care provider.  Though it is just the beginning, this course laid a strong foundation upon which I can hope to build a career and a system that warrants it’s own case in the future! Thanks so much for such a transformative experience!

The Value Proposition of Standardized Care Processes

James C. Etheridge, M.D. 

Resident in General Surgery 

Brigham and Women's Hospital 

PGY 3

06/02/2021

James C. Etheridge, M.D. 

The benefits of standardized care processes are well-established.  Clinical pathways and protocols, when properly implemented, have been shown to improve adherence to evidence-based practices, efficiency of healthcare, and patient outcomes.  Enhanced recovery pathways, for example, have been enormously successful in surgery.  However, the benefits of these approaches are seldom explored from a value perspective.  As such, the Value Based Healthcare Delivery Course helped me to see these approaches in a new light.

Standardized care processes tend to be discussed from a “high-reliability” perspective.  The argument is logical and reasonable: if we can ensure timely adherence to evidence-based practices, patients will do better and leave the hospital sooner.  There is a tacit emphasis on process measures from this perspective – outcomes are frequently presumed to follow improved process adherence.  The only element of value routinely explored is the denominator, most commonly in terms of length of stay.

Certainly, there is a benefit to improving best-practice adherence and streamlining care.  From a value perspective, however, these process-oriented advantages are secondary.  Standardized care practices are, rather, a prerequisite to value-based healthcare delivery.  A health system has no way to assess the costs of care processes and the return on investment for these processes without standardization.

Consider a patient with uncomplicated appendicitis.  A system with a systematic approach to care delivery will be able to predict the choice of antibiotics, operative or non-operative management, surgical devices used, and postoperative care provided.  With this data, the system can anticipate costs and likely outcomes.  Process improvements to reduce costs or improve outcomes can be made and studied with confidence.  A system comprising a conglomeration of individual providers, lacking standardized approaches to patient care, can do none of these things.  Failure to standardize thus does not simply promote errors – it prohibits the functions necessary to a well-designed, value-based healthcare delivery system.

This realization was one of many insights I gleaned from the Value-Based Healthcare Delivery Course.  Sessions on costing methods, organization of care around common conditions or organ systems, and rationalization of increasingly consolidated healthcare systems were thought provoking and stimulating.  Nonetheless, as an implementation researcher with an interest in care standardization, I found this realization profound.  I am thankful for this opportunity to refocus my efforts from processes and outcomes to value.

Necessary for All Residents

Hilary Gallin, M.D. 

Resident in Anesthesiology 

Massachusetts General Hospital 

PGY 4

06/08/2021

Massachusetts General Hospital

I had the pleasure of attending the Value Based Healthcare Delivery Course. It was an opportunity to step outside my clinical duties and explore patient centered care, quality in healthcare, and payment structures. The course taught us how to be successful leaders with a range of leadership styles. In addition to the outstanding faculty, I had the opportunity to meet a number of trainees across the MGB system with different perspectives from multiple specialties and institutions. 

As an anesthesiologist, I hope to use these lessons when approaching projects to improve operations, patient safety, and patient experience. This course was a reminder that as a physician we have a duty to engage not only in medicine but broader healthcare delivery. It provided a vocabulary and structure to start improving care.

Terrific Course for thinking about health system strategy

Gregory James Zahner, M.D., M.S.C. 

Resident in Internal Medicine

Massachusetts General Hospital 

PGY 1

06/02/2021

Gregory James Zahner, MD, MSC

I signed-up to take the Value-Based Health Decisions course to develop a framework for thinking about value-based healthcare that was more than a fashionable buzzword. I have previously worked in healthcare strategy and after residency hope to again work at the intersection of clinical medicine and healthcare management/policy.

In my prior experience, most health systems still define value in monetary terms without relation to patient outcomes. Operational measures are considered to the extent that they reflect efficiency and impact the bottom line (e.g., pre-noon discharges, LOS for a given MS-DRG, etc.). Population needs are rarely considered unless to identify a profitable untapped market. While the transition from FFS to capitated and other prospective payment mechanisms is well underway, health systems still focus on high margin services that tend to be procedural, regardless of value to the patient. For example, one health system was under-penetrated in spine surgery (i.e., lower market share in spine relative to their overall market share). From a finance perspective the estimated “loss” was ~$10M in margin annually, but the reason for the under-penetration was a robust PT and PM&R outpatient program that they had established to non-surgically manage many cases. This program reportedly yielded great patient outcomes, but no financial margin.

Additionally, a lot of current healthcare strategy still focuses on “payor mix optimization.” Given the vastly higher rates paid by commercial insurers relative to Medicare and Medicaid, health systems focus on several levers to improve their payor mix. This includes “aligning” physicians with favorable payor mix, improving their ambulatory footprint by building clinics and ambulatory surgery centers in wealthy suburbs, and investing in service lines with the highest proportion of commercial patients. These strategies can make a health system very profitable and are justified for the purposes of cross-subsidizing healthcare for Medicaid patients. However, the focus on competing for commercially insured patients only reinforces many of the healthcare disparities that exist and destroy value at a societal level.

There were several takeaways from this course that will impact my career. 1) You can be wildly successful with non-commercially insured patient populations through customer segmentation and wrap-around services (e.g., Oak Street). 2) Payor-mix optimization doesn’t have to be the end-all of healthcare strategy. Effective deployment of a network strategy that maximizes optimal site-of-care (e.g., CHOP), integrated practice units organized around diseases (e.g., Cleveland Clinic), and patient-centered outcomes (e.g., Martini Klinik) can all be used to improve value in terms of margin as well as patient outcomes while remaining agnostic to payor mix. 3) Bundled payments are an ongoing improvement project. Although early efforts have been underwhelming, a sustainable competitive advantage can be built by being the first in market to perfect bundled payments for an ever-growing range of high-volume services (e.g., New England Baptist). 

Learning beyond the patient encounter

Giovanni Rodriguez, M.D. 

Resident in Emergency Medicine

Brigham and Women's Hospital/Massachusetts General Hospital

PGY 2

06/09/2021

Doors to the Emergency Room

The VBHD course taught me so much in such a short amount of time. As an intern and with no prior administration training, this course opened the doors to learning more about systems and approaches to creating models. This course has helped me to begin to chip at the iceberg of the health administration/policy world. Although I have no formal training in these systems, I have always been interested in creating access and equitable healthcare. 

This course reaffirmed my interest in learning more about models that are efficient, well rounded, and equitable. I am very interested to continue to learn and apply what I have learned thus far.  I think that more trainees should take this course because as physicians we are always focused on the art of medicine, but we also have the right and privilege to engage in the delivery in the care of our patients.

Valuable Lessons in Value-Based Healthcare Delivery

Frances Y. Hu, M.D., M.S.C

Resident in General Surgery 

Brigham and Women's Hospital 

PGY 3

06/01/2021

Frances Y. Hu, MD, MSc

The Value-Based Healthcare Delivery course was a wonderful exposure to concepts often overlooked in clinical training yet still integral to patient experience and outcomes. With significant restructuring on the part of the organizers, the course had been well-adapted to a virtual format, and the case-based sessions remained engaging and rich with discussion. At the conclusion of many sessions, we had the chance to interact with healthcare leaders who had taken the initiative to implement system-wide change and learn from their experiences.

I particularly enjoyed the small group discussions when we were asked to consider the frustrations we encountered as clinical providers across Mass General Brigham and brainstorm solutions to better integrate patient care and increase value within our own healthcare system. Hearing from trainees in a variety of specialties drew attention to opportunities for improvement we had in common and emphasized the benefits to multidisciplinary efforts in improving care delivery. Overall, the course offers a more comprehensive understanding of the contrasting perspectives of various stakeholders in the healthcare system and allows trainees more awareness of strategies to align value with patient care.

Learning to view healthcare in a bigger picture.

Fei Wu, M.D. 

Resident in Anesthesia

Massachusetts General Hospital 

PGY 1

05/26/2021

The Value-Based Healthcare Delivery course had been a rather mind-opening experience for me. It had allowed me, a clinical trainee to start viewing the bigger picture in healthcare. We can not do the best for our patient if the system is not working in a sustainable, consistent, and efficient way. 

I really liked the concept of focusing on “value”, and discussions on how to organize healthcare in a way to deliver better value for our patients. It was lots of fun to learn about different hospitals and their respective history and development course. 

It even helped me to identify what I am missing in my clinical practices, like outcome measurements. This course had been a cornerstone for me to be more aware of the things I see every day, big or little, and think about its impact on the healthcare system. And hopefully with these concepts I have learnt from this course, I would be better able to contribute to healthcare on an organizational level in the future.

Empowering the Next Generation of Healthcare Leaders.

Douglas Spivak
Administrative Fellow
Massachusetts General Hospital 

06/09/2021

Reading for the Course

The Value-Based Healthcare Delivery course is a great opportunity to learn, discuss, and acquire the knowledge and tools to drive change toward innovative value-based care in our healthcare industry. Not only is this HBS course taught by world-renowned faculty, but the case readings are brought to life when the case protagonist joins the discussion to provide their first-account insight and answer questions from the class. The cases are relevant, recent, and inspiring as the faculty often worked closely with the protagonists to plan, measure, and improve value-based care. This course is so important for young professionals in healthcare because we know this is the future direction of our industry and we have the power influence change together as we progress in our careers. This course allowed me to question the very makeup of our current healthcare system and challenge the realities of our care models, costs, and reimbursement structures.

As an Administrative Fellow, I felt empowered leaving this course to seek opportunities to lead TDABC initiatives in future administrative and leadership roles. I am still surprised by the notion that we as a healthcare industry do not comprehensively know our actual costs. I now view healthcare costs and finance in an entirely new lens. Additionally, this class is a great way to step outside of work mode and focus on learning through insightful discussion with colleagues in different corners of our health system. For me personally, this was a great opportunity to connect with young physician careerists, understand each other’s perspectives, and put our minds together to discuss these emerging trends in healthcare. I realized that our clinical and administrative backgrounds have real opportunity to learn from each other, to collaborate, and to passionately drive the future of value-based care. Ultimately, I encourage future clinical and administrative colleagues to take this course, continue to seek learning opportunities, and work together to drive value. 

To Improve, It Must Be Measured!

Amar Deshwar, M.D. 

Resident in Emergency Medicine 

Brigham and Women's Hospital/Massachusetts General Hospital

PGY 2

06/01/2021

Amar Deshwar, M.D. 

I recently was fortunate enough to participate in the Zoom edition of the Value Based Healthcare Delivery course. A large portion of the course involved case studies of different hospital systems tackling their toughest problems. If you were to ask anyone, individual physicians and hospital systems included, if they wanted to improve patient safety, drive down costs and raise profits my guess is that they would all say of course! But what are they doing to make this happen?

For me, this the point that I will take from having been a part of this course: being able to precisely measure an outcome is the first step towards improving it. This sounds so simple and yet seemed to be the key realization of the majority of these cases in turning around their respective projects. Everyone agrees that healthcare is too expensive and yet determining how much it costs to provide care for an individual’s hospital stay is still evasive. 

For me as an emergency resident in training I think there are many takeaways from this. I hope to be able to translate this into my own practice by tracking the procedures that I perform and having regular evaluations of their various outcomes, as well as accounting and comparing the costs for patients that I see that end up being admitted from the ED to the ICU, the floor or to ED Observation units.