Porter y el laberinto del valor

Photo of unpack

Porter is a horny guy.

I have heard this phrase several times over the last few months. The tone may vary, but the root is always the same: that half a century later invert the numerator and denominator of the Cost-Utility Ratio (ACU) and rename it Value (Porter and Teisberg, 2006) seems like something halfway between a cheap trilerism exercise and a bad joke.

There is something I can’t help but agree with.

Relating results to costs may sound as new as you want out there, but the reality is that university shelves are full of cost-effectiveness and cost-utility articles (Cost per QALY (quality-adjusted life year – QALY in English)) for more than fifty years (Drummond, 2021; Weinstein and Stason, 1977).

And right there lie two important arguments on which I hope we agree and which are the basis on which what follows is based: one, that what Porter says is new, what is said new, is not. And two, the only place where ACU is abundant is on university shelves.

Call me ill-considered, but it seems to me that the first of these arguments has to do with the fact that Health Economics in general has received Porter’s contributions with a certain disdain. And he did it wrongly, in my opinion. Because it is a fact that no one who decides something in the day-to-day life of the sector uses the concept of QALY (or anything similar) in the slightest. And a concept can be elegant (and QALYs are) but completely useless if no one accepts it as common currency.

The truth is that in these times we do not need elegance or sophistication. We need impact.

And to make an impact you have to simplify.

And I don’t mean simplifying in the sense of synthesizing complexity into an index – something QALYs do very well. Rather in the sense of making it understandable – and, consequently, legitimate – for those who must put it into practice.

Why QALYs never took hold: The best is often the enemy of the good.

The abstraction necessary to deal with QALYs can work in different offices. It makes perfect sense from the perspective of a payer, tempted to have a synthetic index that allows it to distribute all its providers on a continuum that legitimately differentiates payments.

But this abstraction, unfortunately, does not go well with the necessary concreteness of daily clinical management.

The patients do not take it well, who would hardly understand that the doctor told us that something is going to impact us on average 0.26 QALY. Instead, we will prefer that it tells us, beyond survival, the effect on our daily life in a clear way: the times we will wake up at night due to pain, or to go to the bathroom, or simply because of the side effect of a certain drug; or how a certain treatment can affect our sexual health or the image that we see in the mirror. We can reach 0.26 QALY in many ways. And arriving one way or another can be night or day from two perspectives and two different health problems.

It is also of no use to physicians, because none understand the association between differential practice and additional QALYs. Without resolving that link, no proposal is a solution.

And all of that brings us to the next point: why does Porter’s speech reach the grassroots, and why is it our best bullet to shake the rug from under our feet?

Why Porter does come?: Simplicity is the ultimate sophistication.

Porter’s speech comes because for the first time in a long time he talks about concrete and relevant things to concrete and relevant people.

To begin with, Porter is liked by healthcare professionals, among whom he inspires coherence and understanding, tired of measuring insubstantial indicators of activity because it was what could be easily measured.

It helps them focus on the problem: it makes them participate in what is relevant to measure. And that depends on each health problem. To the extent that they recognize themselves in the indicators to be measured, they are committed to the results. The ranking of results and alternatives are clear (including patient preferences). The metrics of success, too.

At a time like the current one, there are few more powerful levers to rescue the interest of professionals than to reconnect them with what is essential and with the purpose for which they got into this: impacting people’s quality of life. he Value-Based Healthcare (VBHC) It is a powerful weapon to reengage the clinician. And you have to have been there to see the sparkle in his eyes.

The speech is liked, of course, by patients, tired of an overwhelming lack of transparency that prevents them from harboring a minimum of expectations about the expected development of a health problem. This information is missed at the time of diagnosis. Given the different alternatives. Throughout the process.

Porter’s (and Teisberg’s) music sounds good to (almost) everyone.

There are musicians who dare with the score. They may still sound a little out of tune, but the melody is recognizable. Isolated clinicians. Assistance teams responsible for some process. Supported to a greater or lesser extent by management teams. And for information systems. But always from bottom to top. And with results in hand.

There is only one slight problem: the thing does not finish scaling.

We like the music, but the score ends up seeming too demanding. It is true that there is complexity in the implementation of all this.

In other words: there are barriers to jump.

There are barriers in information systems to measure what is relevant to measure. Less and less, digitization through. The time has never been better: Voice to text. Natural Language Processing for activation of biomarkers. Semantic interoperability. Sensorization of processes. And finally a supranational legislation that requires everyone.

There are also powerful organizational barriers. Focusing on the health problem means, by definition, dynamiting two deep-rooted characteristics of our health system, such as the organization by specialties and the well-known abyss between Primary and Specialized Care. However, it is now common to find teams, such as some multidisciplinary Functional Units for specific pathologies, that draw on that same paradigm.

And there are, above all, barriers to jump in the incentive layer. And that’s where, in my opinion, things really go awry.

Paying for value continues to be the pending issue. I am referring to the purchase of results from healthcare providers, not the purchase of devices or drugs based on value (Value Based Procurement) – which is advancing somewhat because it has always been easier to transfer the risk to private operators.

Porter’s weakest angle requires Health Economics

In summary. There is already a lot we can measure in terms of results and processes. And there are already Integrated Clinical Practice Units with which to pilot and compare results and costs.

We lack the desire to pay for value (which is a big lack).

But for the latter we need to know how to pay. And of all the barriers, this is where things are least clear. And in which the Health Economy can provide the most light.

It must be said that this is exactly where Porter’s proposal really limps: because he brilliantly resolves the micro side of the provider/patient relationship. But he is neither there nor expected to reconcile the “above” model: the payer/provider relationship. Especially in a health system like ours.

For Porter it may not be relevant, because he assumes independent markets due to health problems, with their suppliers and demanders in full competition.

But this is not, for the moment, the United States. And if we want to start paying for health problems over time (and overcome payments for existing at once), a system like ours needs to articulate not only a way of assessing a specific health problem – for which there are very interesting references (García-Lorenzo, Alayo, Arrospide, Gorostiza and Fullaondo, 2024; Walraven, Jacobs and Uyl-de Groot, 2021). We also need to be able to compare that value between health problems. Because only then can we prioritize finite resources among alternative uses.

Ironically, that brings us back to the synthesis logic of QALYs. But if we want it to be of any use, we also need it to rhyme well with the micro perspective that patients and doctors need to advance and improve.

When you try to drill a mountain from opposite sides there is a clear risk: that the tunnel boring machines will not meet halfway.

The ACU approach is one such TBM. Open the mountain from the financier side. And to do this you need the simplicity of a single index.

The VBHC is the second tunnel boring machine. And it opens the mountain from the opposite side: that of the provision of assistance. That side of the mountain needs specificity and multiplicity of measures. Because it is what the patient needs and what allows the healthcare team to align.

In order for us to cross the mountain, we need to be able to connect those two TBMs. And to do this, we need to be able to move along a malleable measurement axis that allows us to expand and contract the unit of analysis at play.

There is a key piece of the puzzle.