Founded in 1908, the Harvard Business School is consistently ranked among the top business school rankings globally. Since 1920, one of the ways Harvard Business School has differentiated itself is by developing and pioneering the case method of teaching. For this approach, teaching is focused around cases. Each case presents a real life complex business situation, containing sizeable qualitative and quantitative evidence to enable the reader to develop analyses and arguments. This method is based on the premise that in business – including the business of health care - there is no one answer, rather several feasible answers. During class discussions, the teacher acts as a conductor - while the students dynamically exchange ideas and perspectives on the key issues for each case, analyzing them and proposing solutions. The teacher may steer the discussion, through observations and questions, but talks for less than 20 per cent of the time. Through countering and defending points, building on each other’s ideas (as well as occasionally being called upon to comment), the goal is that this process sharpens students’ analytical and leadership skills. One not insignificant driver for class participation is that for MBA classes, 50 per cent of a student’s grade is based on the quality of their participation in case discussions.
A master of the case method, Harvard Business School Professor Michael Porter’s core field is competitive strategy. Best known by all MBA students worldwide for his five forces framework, since 2001 Professor Porter has devoted considerable attention to health care, with a focus on health care delivery. In 2006, he published ‘Redefining Health Care: Creating Value-Based Competition on Results’ with Professor Elizabeth Teisberg. Defining value as the health outcomes achieved per dollar spent, Porter has recently published a series of articles in the New England Journal of Medicine, with Professor Tom Lee, on “What is Value in Health Care?” (2010). Given that there are multiple outcomes that matter for patients with any medical condition, Porter presents a three-tiered outcome hierarchy: Tier 1 is for outcomes related to the patient’s health status achieved. Tier 2 includes outcomes related to the process of recovery. Tier 3 includes outcomes related to the sustainability of health.
Last week I participated in Professor Porter’s annual Value-Based Health Care Delivery Intensive Seminar held on the Harvard Business School campus. This was a week of immersion in to a diverse collection of nine separate Harvard Business School cases on health care organisations, ranging from interdisciplinary cancer care at the University of Texas MD Anderson Cancer Centre to spine care at the Dartmouth-Hitchcock Medical Centre and renal transplantation at the UCLA Medical Centre. After dissecting and drilling down into the details at pace for each case, guest protagonists joined the class either in person or by live video link. Medical and managerial leaders from each scrutinized organisation were invited to respond to the recommendations made by class participants and to update on subsequent developments.
In addition to mini topic lectures, Professor Robert Kaplan, also from Harvard Business School, introduced the class to time driven activity based costing (TDABC). Likening healthcare accounting to the Galapagos Islands, in that accountancy practices in hospitals seem to have developed independently of the mainstream, TDABC potentially offers a more accurate model for calculating true costs across the cycle of patient care.
Students (both medical and MBA), doctors, managers and researchers attended the course from the US and internationally. All were passionate about improving health care delivery. No single case we analyzed during the week fulfilled all of the criteria for a value-based health care delivery system. Indeed, no healthcare organization worldwide would or could claim to be achieving perfection in value-based healthcare delivery. Perhaps the case we studied that came closest was the Cleveland Clinic in Ohio. Led by Dr Cosgrove (CEO), the Cleveland Clinic is organized into institutes (or integrated practice units) around patient medical conditions – such as pulmonary, eye and digestive diseases – rather than the traditional model of departments of surgery, medicine etc. Each of these groups within the Cleveland Clinic publicly reported universal measurement of outcomes and cost for every patient. One of the key messages from the cases we studied was that volume in a medical condition enables value. Organising care around specific patient populations, rather than attempting to be all things to all patients, enables value to be improved, as defined by improving clinical outcomes and reducing overall spend.
One of my outputs for this year as a Commonwealth Fund Harkness Fellow is writing a Harvard Business School case considering value in mental health care. I am specifically looking at the management of eating disorders at the Schon Klinik, Germany. Now I am endeavouring to write a case myself, I have even more respect for the cases we learnt from this week.
As English healthcare undergoes a period of “revolutionary” reforms, it is timely that Professor Porter will be sharing global perspectives of value in healthcare at the forthcoming Monitor and UCL Partners meeting in London on ‘Maximising quality, Minimising cost’ at the end of January 2011. The recent publication of the NHS Outcomes Framework may not have included Porter’s outcomes hierarchy, but maybe forward-thinking NHS provider organisations will.
Porter, M. E. Teisberg, E. O. Redefining Health Care. Boston: Harvard Business School Publishing, 2006
Porter, M. E. What is value in health care? NEJM, 2010