The “Four Cornerstones” of value-driven health care

The First Cornerstone of value-driven healthcare is widespread adoption of interoperable HIT [health information technology] to facilitate, among other things, reducing medical errors, enhancing the provision of evidence-based healthcare, and increasing administrative efficiency in healthcare delivery. […]

The Second Cornerstone of value-driven healthcare is measuring and publishing information about healthcare quality. […]

The Third Cornerstone of value-driven healthcare is measuring and publishing information about prices. […]

The Fourth Cornerstone of value-driven healthcare is adopting incentives to promote high-quality and cost-effective care.

Sounds like something describing the provisions of the Affordable Care Act, right? Well, it could be, but it isn’t.

The Four Cornerstones were articulated by Presidential Executive Order 13410, issued by President Bush on August 22, 2006. The sentences above are from Legal Impediments to Implementing Value-Based Purchasing in Healthcare (ungated pdf) by Anne Claiborne et al. (2009, American Journal of Law & Medicine). I understand that many (all?) of the legal impediments described in the paper were addressed by the ACA and subsequent regulations. If I’m wrong, co-blogger Kevin will probably set me straight. If I’m right, he could likely recommend some reading to back up the claim.

My broader point is that value-driven, cost-effective care is not just a Democratic or or just a Republican ambition. It’s a widely shared goal, at least rhetorically. You could predict that knowing almost nothing about politics. Who would willingly go on record against “value-driven” or “cost-effective”? Who is for low value and waste?

On the flip side, knowing something about politics (but not much!) leads to a fairly accurate predication that Democrats and Republicans cannot agree, rhetorically, on how to achieve value-driven, cost-effective care. That is, in broad caricature, they say they fundamentally disagree. But then, when you look at what each side is actually for, as demonstrated by specific proposals they make or the legislation they’ve supported, the differences are not always so great, though there are differences and sometimes they are great.

Policymakers across the political spectrum could agree to agree, but they don’t. They could agree to disagree, but they don’t do that either. They disagree and rub it in each other’s faces. Why? Because it is how to keep the campaign money flowing. It’s how to keep the base charged up. I’m sure you’d lend more support and enthusiasm to a candidate that said, “The other party will destroy America; we will save it.” as compared to one that said “We’re pretty much the same as them.” Of course if it were true that the other party will destroy America, the country would have been ruined dozens of times over by now. It’s plainly not credible (or maybe you think it has already happened). It’s also not true that the parties are interchangeable. There are differences.

Yet, we seem to be living (maybe not in harmony) with these four cornerstones. They’re in law and with fewer impediments than there used to be. “Cornerstones” implies that they form a solid foundation. And they’ve been put in place with bipartisan support, spanning the Bush and Obama presidencies. You’d think we could build something upon this foundation. You’d think having more or less agreed to them we would construct something we broadly think is a worthy improvement to the status quo. Have we? Can we? Will we?

Maybe, but not without a heavy dose of rhetoric that both sides wish to raze the others’ framework. Perhaps in a crazy, uniquely American way we’re “walking the walk” without “talking the talk.”

UPDATE: Someone may ask how the ACA increases price transparency. See Section 2718(c) of the law.


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