# About this Course We find ourselves at a pivotal moment in healthcare, and importantly, in our clinical training. As new physicians, it will be hard for us to change the system, but individually, we can step up so that each small action changes the medical culture for the better. This course will introduce students to the underlying concepts and skills required to deliver high-value medicine, medical care that maximizes outcomes that matter to patients per total cost of care. The course is composed of online modules, weekly discussions, and conversations with local subject matter experts; and it endeavors to build students' understanding of their patients’ intricate physical, emotional, and financial burdens, as well as provide tools for addressing them. The purpose of this online forum is to formalize the course in such a way that its contents can be easily shared across institutions. We recommend taking the materials from this document and transposing them into the online course site most used at your institution (e.g., Sakai, Blackboard, etc.) The course was generated during the COVID-19 pandemic as a 4-week intensive, requiring 20-hours of work per week but it can be repurposed and reorganized to fit your needs. To increase the credit hours for the course, leaders can consider adding a clinical component to both the weekly hours requirement and/or the Final Project. Much appreciation goes to Dr. Chris Moriates, Victoria Valencia, and the entire Dell Medical School team for creating the *Discovering Value-Based Healthcare* modules, and most importantly, for making them freely available for all students. We'd also like to thank the *Costs of Care* team, as well as Dr. Pamela Johnson, Dr. Roy Ziegelstein, Dr. Lenny Feldman, and Dr. Amit Pahwa at HVPAA. All of these inspiring instructors worked tirelessly to create amazing materials, whereas all we did was tie them together into a course for you to take to your respective institutions. Finally, thanks goes to Dr. Sarah Smithson, Dr. Ana Felix, and Dr. Richard Wardrop for their tremendous support helping us get this course off the ground. And, a huge amount of gratitude goes to Dr. Matt Nielsen, Dr. Alice Ma, and Dr. Mark Gwynne who each contributed their time, their experience, and their wisdom to the students during the first run of this elective. Co-facilitated by Emily Fink and Elexis Hollingsworth, MS3s at UNC School of Medicine, this course was student-driven and student-led, and it is continually being improved. Questions, comments, feedback? Please contact course curator, Emily Fink, at # Course Details Course objectives and overall recommended framework **Course Objectives:** \ By the end of this course, students should be able to: * Define value in health care * Consider the outcomes that matter to patients * Understand the fundamentals to healthcare financing * Evaluate innovative approaches to value-based health care delivery * Practice strategies for reducing costs to patients * Communicate effectively with patients and colleagues about high-value care * Critically appraise value-based payment models * Identify tangible methods for adding value to their individual medical practice\ **Overall Course Schema:** As it is currently displayed, the course is organized around two, two-hour class meetings per week. On each day of the week, students are assigned modules and supplementary readings, videos, or other activities; the expectation is that discussions will review the majority of what students look into on their own. Each week includes separate tabs (i.e., "Overview," "Assignments," etc.). The "Overview" tab showcases each day's theme. "Assignments" displays the daily work, plus built-out instructions. Under "Session" tabs, you'll find some discussion questions as well as recommended time stamps for each topic. (The questions serve primarily as jumping off points; see where the discussion takes you!) * Note: *Credit* *needs to be given where credit is due.* Dell Medical School generously provides discussion questions and sample class outlines. A majority of the discussion questions we provide are pulled from these materials; however, we've also added more readings, videos, and activities and provided follow-up questions as well. Many days of the syllabus include suggested but optional Deep Dives on topics related to high value care. High value care is complex and spans multiple spheres; practicing it successfully requires significant clinical acumen as well as an appreciation for Health Systems science. The purpose of many of the Deep Dives is to add counter-arguments and critiques of the value-based movement. We need to know what we're getting into after all! Sometimes the articles in the Deep Dives can make a person feel discouraged -- that's normal; but also, keep in mind that to advocate for, and to enable change, it's important that we consider the perspectives of all stakeholders. For convenience, we've created a separate section that lists out all of the Deep Dives, with embedded links to the area in the syllabus where you'll find the readings/assignments. Below we've defined the various components of the course. * *Class meetings* are at the instructors' discretion but it is recommended that students gather together twice per week. All sessions are be discussion-based; however, a few include lectures from subject matter experts (SMEs). We recommend that course facilitators seek out local SMEs to more powerfully inspire students that they, too, can be change makers at their own institutions. * Principal course content derives from [The Dell Medical School Value-Based Health Care (VBHC)](http://vbhc.dellmed.utexas.edu/) modules. Students will create a free online account and follow the course syllabus to complete all modules. At each module’s completion they will have the opportunity to fill out a survey to receive a certificate of course completion. Students must complete the survey and send verification to course directors to receive credit. We recommend that students take a screenshot of each certificate and add to a Word document. At the course's end, they can submit the Word document. * *Supplemental materials* include readings, related TedTalks and/or online lecture content. Many resources can be found on [HVPAA](https://hvpaa.org/). All resources are available as hyperlinks; PDFs are embedded where possible. Additionally, we suggest times to allot for assignment completion. At various points, students will be offered *"Optional Deep Dives (designated "Opt"),"* which supply resources on tangentially-related topics (see above). Facilitators can decide to assign these and formally review them in the discussion section. * *Mini-Presentations:* There are a few opportunities in the course for students to take charge of the class discussion. These points in the class will be marked "Mini-Pres" in the course syllabus and are accompanied by resources and instructions. * *Weekly Assignments* consist of three short reflections and a final project which students can choose to complete as a pair or individually. * At the beginning of the course, facilitators should make time for a short one-hour course orientation and on the final Friday of the course, a one-hour closing session. During the orientation, facilitators can emphasize that the success of the course depends on student engagement and participation. We found that taking a moment to delineate these objectives helped set the tone for the remainder of the course. **Recommended Attendance Policy:** All in-person sessions are required and attendance will be taken at each meeting. Students are expected to be prepared for, and actively contribute to, the discussions in each session. **Suggested Assignments and Grading:** The course will be graded as Pass/Fail and will not contribute to class rank. Students will need to obtain a 70% cumulative score to pass the course. The weighting of assessments will be as follows: * Small Group attendance/participation \* = 40% * Mini-Presentations: 2-3 students will be assigned to lead a small portion of the discussion. Very informal, no PowerPoint or writing assignment required. * Screenshots of Dell Module Completion Certificates = 10% * Assignments: * Informal reflections (x3) = 30% (10% each) * Criteria: in 250-words or less, students share their main takeaways from the week. These are very informal and can be in bullet-form. * Final Project = 15% * Identify an experience that demonstrated “low value care,” and in a brief abstract or other modality, innovate a solution that might address a similar problem in the future. * Note: students may work alone or with a partner. * Sakai comments on 2-3 colleagues’ work = 5% # Class Surveys We recommend conducting pre- and post-surveys to evaluate student awareness of HVC. This baseline information can help tailor your discussion according to student needs and knowledge level. Suggested questions: * What is your SOM clinical exposure? * I have not done rotations and don't have much clinical exposure * A few weeks of rotations before they pulled the plug on rotations * Completed or pretty much completed all rotations * I have clinical experience outside of the SOM curriculum (nurse, scribe, medical assistant, physician shadowing, etc.) * What specialty are you most interested? Feel free to put more than one. \[Open-ended response] * How familiar are you with high value medical care? \[Open-ended response] * Approximately what percentage of healthcare is estimated to be overuse? * 5% * 10% * 30% * 45% * What is estimate to be the largest contributor to healthcare waste? * Fraud * Exorbitant prices * Executive and physician salaries * Unnecessary services * Administrative error * Physicians have a responsibility to reduce healthcare costs. * No responsibility * Some responsibility * Major responsibility * Physicians should try NOT to think about the cost to the healthcare system when making treatment decisions. * Strongly disagree * Disagree * Agre * Strongly agree * The cost of a test or medication is only important if the patient has to pay for it out-of-pocket. * Strongly disagree * Disagree * Agree * Strongly agree * Physicians who consider cost in their clinical decisions are NOT providing optimal care to their patients. * Strongly disagree * Disagree * Agree * Strongly agree * I have the power to address the economic healthcare crisis. * Strongly disagree * Disagree * Agree * Strongly agree * I would be comfortable discussing the costs of medications with patients. * Very uncomfortable * Uncomfortable * Comfortable * Very comfortable * I would be comfortable initiating a discussion about unnecessary tests or treatments with my team. * Very uncomfortable * Uncomfortable * Comfortable * Very comfortable # Overview Introduction to Value-Based Care ![](https://649813981-files.gitbook.io/~/files/v0/b/gitbook-legacy-files/o/assets%2F-M7M_c6YurD-Y3nCgs9N%2F-M7mxs-BL90mhRjh9Ovq%2F-M7n1YVf2dQtovS9Ly5f%2Fimage.png?alt=media\&token=4ecc428b-8582-404c-a5fa-388306792bac) # Assignments Week 1 ## **Syllabus** | **Monday** | Tuesday | Wednesday | Thursday | Friday | | ------------------------------------------------------------------------------------------------------------------------------------- | ----------------------------------------------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Class Orientation (30') |

Class
(2 hrs)

|

VBHC:
Mods 2 & 3

\*Dive deep into Basics of Healthcare (M3.2) (2 hrs)

|

Class
(2 hrs)

|

ACP:
"Estimate the Impact of Insurance on Patient Outcomes"
(1 hr)

| | VBHC\*: Mod 1 (1 hr) | [CareZooming](https://docs.highvaluecarehub.com/week-1/www.carezooming.com) exploration\* (30') |

Mini Pres\*:
ICHOM

| Click [here](https://drive.google.com/file/d/1Go9UT8XqpdJtvCk2CkLRyDOTZ22p8sxN/view?usp=sharing) for [Dr. Matt Nielsen ](https://www.med.unc.edu/urology/directory/matthew-nielsen-md-ms/)May 2020 recorded talk | Opt: Narrative Medicine Readings\* (1 hr) | | ["How Do We Heal Medicine"]() (20') | |

Mini Pres\*:
BOTM & Chargemaster

| Follow-up reading\* : [A Patient's Viewpoint on a Current Controversy](https://pubs.rsna.org/doi/pdf/10.1148/radiol.2243020024) | Weekly Reflection | | ["Physicians Discuss Choosing Wisely"](http://www.choosingwisely.org/resource/physicians-discuss-choosing-wisely-video/) (5') | |

NYT:
How Measurement Fails Doctors & Teachers (10')

| | | |

Mini Pres\*:
TWDFNR

| | Opt: Equity & HVC \* | | | \*See Further Instructions & Resources ### **Further Instructions & Resources**: *Note: Many of the associated online videos and readings derive from the Dell Modules. Students may view these resources on their own but the reason they are called out as "extra" assignments is to ensure that these specific materials are looked at by all students. Not every "extra" resource embedded in the Dell Modules will be listed in the syllabus.* * **VBHC Dell Modules:** * Students [access](http://vbhc.dellmed.utexas.edu/) the *Discovering Value-Based Medicine Interactive Module Series* and create a free account. The program tracks module completion and offers the opportunity at the end of a "Course" to receive a Certificate (pending completion of the associated survey). * **CareZooming exploration:** * This site aggregates QI/HVC projects and may help inform students' final project. Use it to explore the interventions conducted at other institutions around the country. What were their successes? What pitfalls did they experience? What were their recommendations for follow-up work? Could your potential intervention be an expansion upon previous work? * **Mini-Presentations** * Things We Do For No Reason: * *All students* (1 hr): Go to the website and review a few TWDFNR. * *Student Discussion Leaders* (2 hrs): Present to the class a brief summary on a TWDFNR of your choice. (Preferably, clinical students will be assigned this such that they can include their own experiences into the presentation.) You should be prepared to explain why you chose this TWDFNR. The goal of this exercise is for presenters to convince the rest of the class that this truly is a TWDFNR. At a minimum, you must summarize the TWDFNR, hitting upon all or most of the entry's sections. Additionally, you must comment on whether you believe this to be a low-value practice. What are some downstream implications of this TWDFNR? Briefly consult the literature to support this assessment. You should also include any follow-up evidence on this recommendation. Were there studies of institutions changing their practice due to this TWDFNR? What do society guidelines suggest? Finally, what might be a way you'd want to publicize this information to attendings, residents, allied health, and patients? * ICHOM Exploration * *All students* (1 hr): Please peruse the available standard sets on the ICHOM website. Note that there are disease specific sets (i.e., diabetes) and general/population sets (i.e., older persons). Select one set to explore further. Download and explore the free reference guide for your standard set of choice. You will have to submit your name and e-mail to download the guide. Reflect on how these sets were made and the value of their utility. Potential questions you could ask of yourself include: Do you think it is comprehensive? Missing anything? What societies/physician groups were involved in the making of this standard set? If the standard set references another survey (i.e., PHQ-9) find the survey and prepare general comments. Do you feel that survey is comprehensive enough? Is it validated? How has it been validated?\ A student discussion leader will be investigating the ICHOM sets in detail and may ask you to voice your opinion on some questions regarding the sets (see below!) * *Student Discussion Leaders* (2 hrs): You will be leading a short discussion (\~20 minutes) on ICHOM for your fellow classmates. You will need to schedule a 30 minute call/zoom with Elexis to go over some behind-the-scenes details that were obtained from an ICHOM representative. Look at the assignment description for all students so you know what knowledge they will be coming in with. It will be your job to spark and guide a conversation about the utility of ICHOM standard sets in clinical practice. Example questions you can ask of your classmates include: How realistic you think it is for an individual physician to integrate the use of this standard set into their practice. Should the onus be on the health system within which they operate (i.e., UNC Health)? Will you have time as a physician to evaluate these PROMs and perform process analysis formally or is it enough to simply utilize and evaluate these measures informally? Do you imagine that tracking process and outcome measures would actually hinder your ability to provide quality care as a physician? Are the surveys referenced in the standard set free? Do you feel like all of the measures in the standard set are already largely being addressed in the clinic? If so, what is the point of the ICHOM standard set? * Bill of the Month & Chargemaster * *All Students* (1 hr): Review the BOTM webpage and read through a few of the cases. Please attempt to find your institution's "Chargemaster." * *Student Discussion Leaders* (2 hrs): Pick a BOTM case that speaks to you and be prepared to present your choice to the class. Also, please search for "The Chargemaster" of three institutions (2 in your home state and 1 in a state of your choosing). In addition to giving us a brief summary of the case, some other prompts to consider: * 1\) Why did you select this BOTM? Have you or someone else you know experienced something similar? * 2\) What happened to this patient? What procedure or treatment did they receive and why? Whose fault is this? The doctor? The patient? The payor or the institution? What could have been done differently? * 3\) How do the charges across selected institutions vary? Were you surprised? Why or why not? How do the charges compare with what the BOTM patient experienced? * **Opt: Equity & HVC** * Remember, HVC is patient-centric care. It's about understanding the totality of our patient's needs and the forces outside of them that might influence those needs (i.e., SDOH). In the wake of the George Floyd protests, legendary Prof. Emeritus at The IHI Don Berwick shares his take on how we can restructure our healthcare system. He presents some solutions for how we might create a system that transcends the "[moral determinants of health](https://jamanetwork.com/journals/jama/fullarticle/2767353?resultClick=1)," wherein we commit to the shared vision of "securing the health of communities." Only then, by adhering to a morality that first and foremost recognizes health care a human right -- can we begin to address the social determinants of health. * Another way to think about equity is to consider innovative approaches to guaranteeing healthcare for our most vulnerable patients. LA County Department of Housing Services worked with community, healthcare, and social services leaders to develop a comprehensive, collaborative program, "Housing for Health," for its homeless population. Built around the principle that ensuring housing first can lead to improved health outcomes, the Housing for Health program is a remarkable case study of an enormously diverse city's successful approach to addressing healthcare in its homeless population. {% file src="/files/-MA1M3VCu819j6WZm5W-" %} * **Follow-up Reading**: [**A Patient's Viewpoint on a Current Controversy**](https://pubs.rsna.org/doi/pdf/10.1148/radiol.2243020024) * This is the editorial mentioned in Dr. Nielsen's talk about the radiologist who received a seemingly benign imaging study which led to a cascade of unnecessary tests. * **ACP Modules** * Students have the opportunity to solidify content learned this past week. They must create a free online account with ACP. * **Opt: Narrative Medicine readings:** * Optionally take a short detour to the realm of medical humanities. These articles introduce "narrative medicine," and argue how it can and should shape the practice of medicine. Course facilitators can choose to bring this up into the next session, connecting how the principles of narrative medicine coincide with the objectives of the value-based medicine movement. * Readings (PDFs below): * Charon, R. (2004). Narrative and Medicine. *N Engl J Med, 350*(9), 862-864. (20') * Charon, R. and Wyer, P. (2008). The Art of Medicine: Narrative Evidence-Based Medicine. *The Lancet*, *371*(9609)*,* 295-297 (20') * Lewis, B. (2011). Narrative Medicine & Healthcare Reform. *J Med Humanities, 32*(9), 9-21 (50') {% file src="/files/-M7oDY70Y0tdKRQv4kxc" %} {% file src="/files/-M7oDTbalG9YDweAR78q" %} {% file src="/files/-M7oDPURPCkd61mgG4AN" %} #### # Orientation This section contains all of the suggested discussion questions for class meetings. **ORIENTATION (Optional)** * **Course Introduction** * The primary goal of this course is to teach the foundations of healthcare value and discuss how you can apply these concepts to your current and future medical practice. * The content is primarily online -- the majority of the materials derive from Dell Medical School’s free online module series but you will also have assigned readings, lectures, and videos from other resources. You’ll notice that some of the assigned readings or videos come directly from the “extra resources” from the Dell Modules. The ones identified in the syllabus are required; you are welcome to further your knowledge with the other resources not explicitly required in this course. * Housekeeping items (tailor as necessary): Discuss course objectives, course structure, pre-survey administration * Be prepared for speakers. Come with questions; be present; be engaged. # Session 1 This section contains all of the suggested discussion questions for class meetings. **SESSION 1:** * **(10’) Welcome Back** \* * Opener: Reflect on a “low-value care” experience (in prep for the Final Project; optional to utilize the shared experience as your FP idea). Share experiences that either you’ve personally experienced as a student, patient or family member. You will have the opportunity throughout the course to reflect on that experience and, with a partner or as an individual, discover ways to improve upon that experience in the future, whether it’s through innovating a systems-wide change, implementing education materials, identifying practical, tangible steps for avoiding this pitfall at the bedside. As we go through the course, we will explore many different ways that HVC has been implemented at all of these levels so through the course, you will be able to assess what is the appropriate modality for your project. * At the end, you will post your final project to Sakai and it is expected that you will comment on classmates’ work. Reflecting/commenting on classmates’ projects is worth 5% of your total grade. * **(5’) Discussion on Results of Pre-Survey** - *Optional to conduct a pre-survey* * **(45’) Discussion on Module 1**: Module 1 introduces the concept of value in health care, the scope of “waste” and inefficiency in the current healthcare system, and how it can be integrated into daily clinical practice. \* * Prompts for discussion: * Any general impressions/reflections, or new interesting things learned? *\*\*Opportunity to share experiences from clinic\*\** * Were you surprised by the way that Dell defines “value?” How have you thought of the word? How would you define it? (For example, prior to this course, I thought value was “doing what we always do in the cheapest, most affordable way possible,” or “doing what we want to do in the most cheap, affordable way possible.” * Recall: Value = outcomes that matter to patients/total costs of care * How do the core tenets of medicine come into conflict with a fee-for-service healthcare system? (i.e., maleficence, beneficence, patient autonomy, justice) * The number one contributor to health care waste is unnecessary services. Does this surprise you? Can you think of any examples of unnecessary care you have experienced, whether as a medical student observing another clinician, as a patient, or something a family member experienced? * Potential discussion starters: imaging desired by patients, lack of ease of data transmission and general lack of communication between facilities, fear of malpractice, unnecessary antibiotic prescriptions. * What do you think are the biggest barriers to moving from a volume-based health care system to a value-based health care system? * Potential discussion starter: the way providers are paid in a fee-for-service system, lack of coordination of care, lack of access to data on outcomes that matter to patients. **\*\*10 min break\*\*** * * **(30’) Recap Atul Gawande TedTalk:** * Intro: Dr. Gawande identifies three skills: * 1\) Identify where your failures are; 2) devise solutions; 3) the ability to implement * Dr. Atul Gawande talks about ways that his institution reduced surgical complications through the implementation of checklists. What are your thoughts on check-lists or algorithms implemented into the practice of medicine? How do we balance the “art” of medicine and simultaneously ensure consistency in the care delivered? * How does it make you feel, transitioning the idea of medicine where you as the doctor are the “cowboy” to medicine where you are a member of a “pit crew?” How do you think we can empower physicians to feel both like the leader of the team as well as a member of the team, and derive personal and professional satisfaction from those roles? * As a class, tease out the difference between checklists (as in safety checks before surgery) and clinical algorithms. While tempting to group both of these under one "checklist" category, there are important distinctions that should be made. * I.e., Some checklists are about safety; others try to ensure diagnostic and treatment consistency. * **Comments on the Choosing Wisely video -** * What have you heard about this campaign before? * What are your thoughts on the story highlighted in the video where an incidental lung nodule was identified and turned out to be benign? The story feels powerful; and yet - what would’ve happened if it wasn’t benign? Is disease only that which causes symptoms? * Do you feel confident in your ability to identify what’s a low- versus high-value test? * Clinical students, please comment on your ability to do this in the clinical setting. * At the end of the video, the physician says that “Choosing wisely for me is doing what’s best for the individual patient, not always doing what’s the easiest thing.” How do we balance that sentiment with the pit-crew mentality? * **(15’) Student volunteers discuss their chosen “Things We Do for No Reason.”** * Give a brief rundown on the “Thing,” and suggestions from SHM to avoid this pitfall. * **(5’) Wrap-Up** \* * Take time after this session to reflect on the discussion and either identify a partner or decide you’d like to work alone on the final project. You will share this decision at the end of the week by email. * Explanation for *CareZooming* exploration + review/questions of assignments for Thursday: * We imagine that a lot of the projects will benefit from solutions that are rooted in QI protocols. The course will briefly touch on various QI methodologies - so this is not something to worry about yet. That being said, CareZooming.com (link provided above) is a great resource that aggregates current and past projects conducted at various institutions across the country. You may find that an institution has already tried tackling the issue you’ve identified and it may be helpful to see what they did to address it, what worked, what didn’t. # Session 2 This section contains all of the suggested discussion questions for class meetings. **SESSION 2:** * **(5’) Welcome back** * Students share any updates for the class; any comments lingering from the first session * **(60’) SME Speaks + Q/A** * Recorded talk by Dr. Matthew Nielsen **\*10 min break\*** * **(25’) Module 2 + NYT article** * Module 2 focuses on the importance of measuring outcomes that matter to patients * (15’) Prompts for discussion: * Anything new or interesting gleaned from this Module? * The module asked us to reflect on someone you know (yourself, a friend, or a family member) who has had a serious medical condition or chronic disease that significantly affected their life, such as cancer, diabetes, or congestive heart failure. What do you think mattered most to them? * We learned that outcomes depend on factors both within and outside of health services (i.e., a patient with an MI survives -- has a good outcome -- but received bad care) and conversely, a patient can have a bad outcome even when the process that was carried out with good compliance. So, which do you think are easier to track and obtain: process or outcome measures? Why? Is one type better than another? * Potential discussion starters: process measures are easier to collect but do not tell us if what we are doing is impacting outcomes that matter to patients. Both are needed to drive change. * Recall: * Process Measures: what is actually done in giving and receiving care (i.e., whether a pt got flu shot during hospitalization) * Structure Measures: the material, human, and organizational resources available in the settings in which care is delivered. (i.e., # of MRI machines) * Balancing Measures: Efforts to ensure changes do not result in other unintended consequences or effects (i.e., measuring # of pts discharged before noon - does it result in more pts staying overnight?) * Outcome Measures: The effects of care on the health status of patients and populations (i.e., the mortality benefit from giving everyone a flu shot). * The NYT piece writes, “We also need more research on quality measurement and comparing different patient populations. The only way to understand whether a high mortality rate, or dropout rate, represents poor performance is to adequately appreciate all of the factors that contribute to these outcomes — physical and mental, social and environmental — and adjust for them. It’s like adjusting for the degree of difficulty when judging an Olympic diver. We’re getting better at this, but we’re not good enough.” * Do you think that measuring PROMS can improve physician outlook on the job and potentially alleviate burnout? What would need to be done to enable good outcome measurement and preservation of physician mentality and outlook? * For Clinical students: one comment that stuck out to me was the idea that discharging patients prior to noon ended up increasing the length of stay for certain patients such that some were kept another night so they could be discharged before noon the next day. On your rotations, what kinds of seemingly arbitrary systems or processes did you notice or participate in and/or question? What might be a better metric to measure? Is it outcome- or process-oriented? * What did you think of the radar charts? Had you seen or used one before? Do you think they are helpful in visualizing how different treatments affect outcomes? * Potential discussion starters: the outcomes look very similar for most domains and different in a few -- this can help patients weigh their options. * ![](https://lh3.googleusercontent.com/nRrf0DaV4ULBw0oTj9lNg9G9Zq6FQ19QSufvkyBd7QMVSwfCP68CH6QzRbxpKYmRSq6KxQDicPpXORfrxua8mucpymrg1VOLyskj2KJPHtwzfbb0gN4PlTY7bKTpoPqgcC0a_Mdy) * This radar chart depicts that the long-term benefits of PCI are negligible, even though in the beginning (6 mo post) it seems to be more beneficial than OMT. Over time, the chance of heart attack ends up being the same with the two interventions. Recall that the values on the outside of the Ring derive from the PROMs identified by ICHOM. * **Mini-Pres: ICHOM: Student representative(s) discusses their ICHOM selection (10’)** * How much is on the physician, how much is on the institution? * Realistically what does this look like? * I’m a PCP, do I have to put it all in the EMR? Do I have to analyze all this data? * How would this data be procured? * **(25’) Module 3** * What are some reasons that physicians might avoid discussing cost with their patients? * What model - that which was employed by VDO versus TDABC seems more feasible for implementation? * What did you think of the exercise at the end of module 3, calculating up what patient Grace Chen would potentially have to pay if she were to go to the ER for an asthma exacerbation? * Optional to quote; the following comes from a JAMA article *(Kensaku Kawamoto, Cary J Martin, Kip Williams, Ming-Chieh Tu, Charlton G Park, Cheri Hunter, Catherine J Staes, Bruce E Bray, Vikrant G Deshmukh, Reid A Holbrook, Scott J Morris, Matthew B Fedderson, Amy Sletta, James Turnbull, Sean J Mulvihill, Gordon L Crabtree, David E Entwistle, Quinn L McKenna, Michael B Strong, Robert C Pendleton, Vivian S Lee, Value Driven Outcomes (VDO): a pragmatic, modular, and extensible software framework for understanding and improving health care costs and outcomes, Journal of the American Medical Informatics Association, Volume 22, Issue 1, January 2015, Pages 223–235,* [*https://doi.org/10.1136/amiajnl-2013-002511*](https://doi.org/10.1136/amiajnl-2013-002511)*):* * For example, labor costs in a hospital unit are allocated to patients based on the hours they spent in the unit; actual medication acquisition costs are allocated to patients based on utilization; and radiology costs are allocated based on the minutes required for study performance. Relevant process and outcome measures are also available. A visualization layer facilitates the identification of value improvement opportunities, such as high-volume, high-cost case types with high variability in costs across providers. Initial implementation was completed within 6 months, and all project objectives were fulfilled. The framework has been improved iteratively and is now a foundational tool for delivering high-value care. * This cost allocation is determined by customizable cost methods that are applied to designated costs in the general ledger. These cost methods may include the allocation of large groups of costs (eg, a hospital unit's personnel costs) based on a patient's estimated usage of that resource, as well as the assignment of actual costs (eg, medication acquisition costs) based on a patient's actual usage of that resource. Virtually all costs are accounted for, and updates can be made both to cost methods and to the specification of which methods should be applied to which general ledger cost * Do you think TDABC is the answer to clearing up the opaque pricing structure? * Potential discussion starter: one major issue with TDABC is that it is very time consuming and very difficult to measure for only one process, let alone hundreds that occur every day in a health care setting * **Mini-Pres: “Bill of the Month”:** 2 students representatives discuss their BOTM () * What are your thoughts on the “Chargemaster?” (Referenced on the UNC website): “As of 1/1/2019, all hospitals in the U.S. are required to publicly post charges for hospital-based procedures, services, supplies, prescription drugs, and diagnostic tests, etc.” Even though we can now look up these charges, how helpful is this information to the average patient? Why or why not? * Potential discussion starter: we don’t know how these prices were derived… * At the end of the Chargemaster video, the narrator states that while physicians do not set the charges on the chargemaster they can still “advocate for a more rational hospital pricing system and can help shine a light on hospital costs.” How do you propose that physicians could go about doing this? * **(10’) Wrap-Up** \* * The ACP put out HVC activities on their website. Students must create a free account. Periodically, the course will assign cases through this program to reinforce what we’re discussing in class. * Friday’s reflection is due by 5p. These are very informal touch points for us to see what you biggest takeaways from the week were. You can write this in bullet form if you like! * Email a brief summary statement on your plans for the final project. If you decide to work with another person, please let us know. * Friday also includes readings that touch on the subject of narrative medicine. This may seem to be from way out in left field but we encourage you to put aside those thoughts and think about ways the narrative medicine and value-based medicine movements are similar. We will briefly discuss these similarities and differences in our meeting on Tuesday. * Please share any feedback you have for the course so far. # Overview Value-Based Healthcare Delivery ![](https://649813981-files.gitbook.io/~/files/v0/b/gitbook-legacy-files/o/assets%2F-M7M_c6YurD-Y3nCgs9N%2F-M877gBJACfUZ5J7CLyB%2F-M87ALlYPg6Pm3niA73l%2Fimage.png?alt=media\&token=0ca24fbe-78dd-40d1-8b27-5ee597594119) # Assignments Week 2 ## **Syllabus** | **Monday** | Tuesday | Wednesday | Thursday | Friday | | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------ | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | VBHC: Mod 4 (1˚10') |

Class
(2 hrs)

|

VBHC:
Mod 5 (1˚)

|

Class
(2 hrs)

| Mini-Reflection | | Mini-Pres\*: PCMH vs IPU | | [Intro to Choosing Wisely](https://modules.choosingwisely.org/modules/m_03/default_FrameSet.htm) \* (2˚) | Click [here](https://drive.google.com/file/d/1YWBuPfUkB2asVJKY9Hg2vnhXFqnMl-eg/view?usp=sharing) for May 2020 recorded talk with [Dr. Alice Ma](https://www.med.unc.edu/medicine/directory/alice-ma/) | ACP: [Eliminate Healthcare Waste ](https://www.acponline.org/clinical-information/high-value-care/resources-for-clinicians/online-interactive-high-value-care-cases)(30') | | Peruse ["WellMed" ](https://www.wellmedhealthcare.com/)website, [TeamSTEPPS](https://www.ahrq.gov/teamstepps/instructor/videos/ts_TeamSTEPPS_Overview/TeamSTEPPS_Overview-640-480.html) (15') | | CW Society Guidelines: [American Society of Hematology](https://www.choosingwisely.org/societies/american-society-of-hematology/) |

Learn more about the

FWGBD

| | | ["Overkill"](https://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande) by Atul Gawande (1˚) (PDF below) | | CW Society Guidelines: [American Society of Hematology-American Society of Pediatric Heme/Onc](https://www.choosingwisely.org/societies/american-society-of-hematology-american-society-of-pediatric-hematology-oncology/) | Read about another affiliate clinic (PDF below) | | | ["The Strategy that will Fix Healthcare"](https://hbr.org/2013/10/the-strategy-that-will-fix-health-care) (1˚) (PDF below) | | | | | | ["What the Healthcare Debate Still Gets Wrong"]() (45') | | | | | | Opt: Reflecting on Hotspotting and Value Stewardship | | | | | ### **Required Readings (PDFs)** {% file src="/files/-M87NOn51QfRfsG72qAi" %} Monday Reading 1 {% endfile %} {% file src="/files/-M87NFmkidTyi6gZ3Q4E" %} Monday Reading 2 {% endfile %} ### **Further Instructions & Resources**: * **Mini-Pres: PCMH vs. IPU** * *All students* (1˚): Please read the articles below and be prepared to discuss tomorrow. (Note: these are extra resources in the *Dell Modules*) * [American Medical Home Runs](https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.28.5.1317) (30') * [IPU, Part 1](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5014838/) (10') * [IPU, Part 2](https://sakai.unc.edu/access/lessonbuilder/item/1937877/) (10') * *Student Discussion Leaders (2˚*): You will be leading a short class discussion on PCMH vs IPUs. The articles in the Dell Modules are a few years behind, so you are tasked with finding updated information on these models. We have included some articles as a jumping off point and expect you to look for additional articles to prepare yourself to lead a discussion. To assist you, the course leaders can distribute some discussion questions to asked of the class. * [Association of High-Cost Health Care Utilization with Longitudinal Changes in PCMH Implementation ](https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2760027)(20') * [The PCMH: Expensive and in Need of Repair](https://www.managedcaremag.com/linkout/2018/5/36) (5') * [2013 Review on PCMH](https://pcmh.ahrq.gov/page/medical-home-what-do-we-know-what-do-we-need-know-review-earliest-evidence-effectiveness-of-the-patient-centered-medical-home-model) (30') * [2017 Evaluation of PCMHs](https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.1235) (20') * [American College of Physicians, page on PCMHs](https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.1235) (10') * [2017 RCT on IPU](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0168757) (30') * **Opt: Reflecting on Hotspotting and Value Stewardship** * Optionally review the two other Atul Gawande pieces mentioned (and heavily critiqued) in the article, *What the Healthcare Debate Still Gets Wrong*. Facilitators can choose to assign all or some of these articles and decide whether to compare/contrast the arguments made by Gawande vs. Gaffney. Essentially, Gawande's articles discuss how "overdiagnosis and overtesting" (argued in *OverKill* & *Cost Conundrum*) and "super utilizers," (argued in *The Hot Spotters)* are huge contributors to healthcare waste and gross overspending in the U.S. whereas Gaffney, in review of Uwe Reinhardt's book, suggests that healthcare pricing and policy are principally responsible. By the way, a recent NYT piece (also included) highlights how recent research into hotspotting programs shows they are not as effective at reducing healthcare costs as everyone hoped. {% file src="/files/-M8qz6mBNY8jEn0UTWB-" %} Cost Conundrum {% endfile %} {% file src="/files/-M8qzCFrRRoBNWTac3BB" %} Hotspotters - Who are the Pts? {% endfile %} {% file src="/files/-M8qz\_WWAd743HXG5zEo" %} Hotspotting {% endfile %} * **Intro to the *****Choosing Wisely***** campaign**: * Facilitators can decide which society guidelines to recommend to students. In the May 2020 elective's Thursday discussion section, UNC students heard from Dr. Alice Ma (renowned hematologist), so we chose hematology society guidelines (also because she contributed to their development). In her talk, she discussed the innovative, IPU-like Bleeding Disorders clinic that she helps run at UNC. It is an affiliate clinic with the Foundation for Women & Girls with Bleeding Disorders, and multiple institutions across the country boast such institutions. Further reading has been provided, as well as the link to Dr. Ma's talk. {% file src="/files/-M87NmngmnAKA5t8sFhJ" %} More info on Bleeding Disorders Clinics {% endfile %} # Session 3 This section contains all of the suggested discussion questions for class meetings. **SESSION 3:** * **(5') Welcome Back** * Students share any updates for the class; any comments lingering from the last session * ***Optional***** (10') Discussion on Narrative Medicine readings** * Narrative and Medicine was provided to give you an idea of what “narrative medicine” really means. In essence, it’s a term coined by Dr. Rita Charon that encompasses the process of attentive listening and reflecting for doctors. * Have you tried reflecting through writing during your clinical training? Or have you been instructed to do so? How has that helped you, or not? Do you agree that illness reveals itself in “stories?” * We’ve discussed that an important component to delivering high value care is identifying and treating towards the outcomes that matter to patients. How do the goals of Narrative Medicine as identified by Dr. Rita Charon coincide with those of HVC? * In *The Art of Medicine*, Dr. Charon discusses how, with difficulty, medicine traverses multiple spheres: the known/unknown, the universal and the particular, the body and the self; and that through taking a narrative approach (i.e., via narrative medicine), clinicians can begin to resolve these tensions. Illness, as she says, reveals itself through stories; yet evidence-based medicine has been touted as a preferred approach to delivering medical care. She challenges the claim that EBM and narrative medicine clash and instead has developed a program -- evidence-based narrative medicine -- that teaches students the value of evidence found in a multitude of texts. * “EBM has earned the reputation of dismissing the importance of the singular predicament of the patient and the individual judgment of the doctor.” Do you agree that if we practice EBM we necessarily negate the individualistic needs and desires of our patients? * What are your thoughts on the “clash” between evidence-based medicine and “the narrative singularity of both patients’ and clinicians’ lived experience?” (Charon 2008). Do you agree with Dr. Charon that there are ways to reconcile the “differences” between these two approaches? * The article *Narrative Medicine and Healthcare Reform* asks the crucial question: “what kind of healthcare do we want?” Writing in October 2010, five months before the passage of the ACA, Bradley discusses how narrative medicine, as complicated as it is to define, may be able to help us build a better healthcare system. Bradley argues that the U.S. medical education system developed to prioritize “objective,” (i.e., medical facts) over the “subjective” (raw human experience.) * Do you think that medicine as it stands today has lost its human aspect? * Do you believe your medical education thus far has balanced the objective with the subjective? * How do you see the value movement as panacea for modern medicine’s failures? * What are ways we can bridge the health system’s goal of identifying and tracking PROMS with that of the physicians -- to address patient goals on an individual, case-by-case basis? * **(20') Discussion on *****Overkill*** \* * In *Overkill*, Dr. Gawande explores the concept of “low-value care,” drawing upon both his own experience as a surgeon and that of stories relayed to him by patients. Through this exploration he makes visceral the problems that come from overtesting, overdiagnosis, and overtreatment. He also defines the “virtuous patient,” as a necessary player in the healthcare system. This is someone who does their research and makes informed choices before embarking down a particular care plan. * What are your thoughts on the adage “he’s a surgeon so he’ll recommend surgery”? As a future doctor, how do you think you can balance focusing on your specialization without neglecting the value of other specialities? * Discuss the pros/cons of testing when there are no symptoms. How can we relate this to the COVID19 crisis? * Thinking about the concept of time in medical visits -- how does more time with patients cut down on medical costs? * **(20') Discussion on *****What the Healthcare Debate Still Gets Wrong:*** * In a review of Uwe Reinhardt’s book, *Priced Out*, this author criticizes Dr. Gawande’s arguments brought up in an earlier article he wrote (which he referenced and followed up on in *Overkill*) where he implies that to change the excessive waste generated in our healthcare system (due to “needy” patients (i.e., over utilizers) and “procedure-happy providers”), we can “keep the market intact” and just “realign market incentives.” In contrast, Reinhardt argues that actually, it’s not how *much* healthcare we are using but *how much our healthcare costs* thanks to price gouging by insurers. * Whose argument do you buy -- Gawande’s or Reinhardt’s? * Do we need more robust evaluations of models like ACOs in order to support a transition to them? Or, is Reinhardt right - it doesn’t matter how you slice it and change our healthcare model: if we don’t fix the financing, we won’t fix healthcare? * **(5') Discussion on *****The Strategy that will Fix Healthcare*** * This article lays out Porter and Lee’s thesis - to create a value-based healthcare system, we must first define the goal, and the goal needs to be prioritizing patient outcomes. Their approach includes: creating IPUs, measuring outcomes and costs for every patient, moving to bundled payments for care cycles, integrating care delivery systems (note: as of 2013 when the article was published, “most multi-site organizations are not delivery systems, at least thus far, but loose confederations of largely stand-alone units that often duplicate services”), expanding geographic reach, supporting a comprehensive IT platform. * Porter’s article talks again about measuring outcomes that matter to patients. What are some examples that he lists versus the outcomes that doctors might be used to measuring? * *There are three Tiers to outcomes: Tier 1 involves the health status achieved (i.e., functional status); Tier 2 relates to the nature of care cycle and recovery; Tier 3 relates to health sustainability (i.e., how long does that new hip last?)* **\*\* BREAK \*\*** * **(1 hr) Discussion on Module 4 & Mini-Presentation: IPUs/PCMHs \*\*** * *\*\*Course facilitators should send the IPU/PCMH questions ahead of time to Mini-Prezzers* * This module discusses incremental and systemic changes that can be made to reduce problems associated with healthcare and details two healthcare delivery models that aim to address the problems associated with uncoordinated care and fragmentation. * What are some challenges that a PCP faces to coordinate patient care? Do you think the responsibility should be the PCPs? * What is the fundamental difference with integrated practice units (IPUs) when compared to the way most healthcare is delivered in the U.S.? * *In IPUs, care is organized around the needs of the patient, rather than by the expertise/specialty of a given health professional.* * Would you want to work in an integrated practice unit? Why or why not? * *Ensure the group highlights the benefits of IPUs for physicians and other health professionals; for example, better health outcomes, lower costs and more efficient cost accounting, better ability to have input and coordination across cycle of care, shared decision-making process between all providers and their patient, lowers burden of trying to coordinate with disjointed, non-co-located providers and susceptibility to malpractice risk.* * Would you want to obtain care at an IPU? Why or why not? * *Well-organized and high-functioning IPUs provide patients with more efficient, patient-centered and organized care that is less susceptible to repeat testing, uncoordinated care, risks associated with lack of communication, higher costs of care, poorer outcomes, and higher focus on measuring and obtaining patient-prioritized outcomes.* * PCMH reps discuss pros/cons of PCMHs. What do recent data suggest about PCMH efficacy? * While patient-centered medical homes and IPUs have similar fundamentals and components, how are they different? * *As stated in the module, “PCMHs and IPUs grew from different gardens but ultimately seem to have converged on the same underlying principles. While PCMHs provide longitudinal care over a patient’s lifetime and generally regardless of his/her condition, IPUs tend to concentrate on conditions for which the care cycle is well-defined. IPUs treat patients with specific circumstances or conditions, including specialty care. IPUs are generally co-located, multidisciplinary teams of clinical and nonclinical providers (e.g., case managers, social workers, activity coaches) who treat circumstances or conditions over a full care cycle. Whereas PCMHs are for generalized care of all patients, IPUs develop solutions for patients who share a condition or set of circumstances (e.g., MSK pain, frailty, or breast cancer).” It is possible to think about settings where PCMHs and IPUs could work together (for example, a patient is cared for at a PCMH but when he develops knee pain is referred to an MSK IPU which communicates with his PCMH and the patient returns to the care of PCMH following full management of his knee pain. Another example could be a patient in a PCMH who is diagnosed with cancer and then is referred to a cancer-based IPU for primary oncology care and management.)* * *As support for PCMHs, the ‘American Medical Home Runs’ article notes how four examples of primary care sites in the US reduced costs by 15-20% without sacrificing quality of care.* * Optional: Discuss some of the findings from the JAMA article (Association of High-Cost Health Care Utilization With Longitudinal Changes in Patient-Centered Medical Home Implementation) on the challenges regarding PCMHs, which measured longitudinally the effects of PCMHs on reducing healthcare expenditures. * What challenges are there in creating team-based, rather than individually-run practices and clinics? * *Potential discussion starters: the way providers are currently reimbursed, lack of processes or appropriate use of HIT, fragmentation between clinics* * **(5’) Wrap-Up** # Session 4 This section contains all of the suggested discussion questions for class meetings. **SESSION 4:** * **(10’) Welcome Back** * Students share any updates for the class; any comments lingering from the last session * **(60’) SME Speaks + Q/A** * Recorded talk by Dr. Alice Ma * ***Optional*****:** If possible for your institution, you should consider asking your SMEs and/or faculty about the process for creating Choosing Wisely guidelines. Some suggested questions are below. * Describe the process of developing these guidelines? * How are you reviewing evidence? What guidelines are you using/referring to principally? * How do you control for conflicts of interest? * How do you decide what’s wasteful? Is it from your own experience and then you share with others, who feel the same? * **(30’) Discussion on Module 5** * This module continues to explore and clarify how the components of value-based healthcare delivery can be applied. * What concepts were clarified for you in this module? * Are there any components of value-based healthcare delivery that we currently do a good job at achieving in our health system? Which components do you think we could most likely work on implementing? * *Components discussed in module include: team-based care interactions organized around patient medical needs and conditions; integrated care across units and facilities; measurement focused on patient health outcomes; the actual costs of providing patient care are measured and captured; providers are reimbursed on value of care provided across a full care cycle for medical conditions; health information technology is leveraged to help restructure care delivery and accurately measure results.* * Would you want to work for a place like CareMore? Why or why not? * Do you believe this model could be a proxy for chronic condition-based IPUs? * This module discussed the Choosing Wisely campaign. One of the simplest ways to improve value for patients is to simultaneously improve care and decrease costs through cutting out unnecessary services. Eliminating areas of overuse, or “waste,” is something that any of us within healthcare contribute to on an individual level. Like the animation in the module said, “it will take countless marginally incremental efforts from all involved.” * How can you help contribute to the movement to decrease overuse for your patients? * As a medical student, do you see yourself using the app in practice? * *Participants can refer to a Choosing Wisely list relevant to their specialty or level of training to identify potential target areas. We can also help have conversations with each other and with our patients around healthcare value and “choosing wisely.’* * What was your experience exploring the Choosing Wisely website and/or app? * Were you able to review any of the Physician Society online modules? Any that seemed helpful? **(10’) Wrap-Up** # Overview Improving Value at the Bedside ![](https://649813981-files.gitbook.io/~/files/v0/b/gitbook-legacy-files/o/assets%2F-M7M_c6YurD-Y3nCgs9N%2F-M8N1bF5dvhKJaGEN8jp%2F-M8N9xzBWwT4o7VOsxTv%2Fimage.png?alt=media\&token=b272bc18-28a2-405f-8f6c-8ae3e8c11a66) # Assignments Week 3 Improving Value at the Bedside ## **Syllabus** | **Monday** | Tuesday | Wednesday | Thursday | Friday | | ------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------- | | VBHC: Mod 6 & 7 (2˚)\* | Rx-Lowering Activity (complete before class) (1˚) | Order Wisely Exercise\* (1˚) // Optional Mini-Pres Opp |

Class
(2˚)

| Mini-Reflection | | Watch the [Costs of Care ]()video series (40') |

Class
(2˚)\*

| NYT: [Why your Pharmacist Can't Tell You that $20 Prescription Could Only Cost $8](https://www.nytimes.com/2018/02/24/us/politics/pharmacy-benefit-managers-gag-clauses.html) (15') | Click [here](https://drive.google.com/file/d/1eOEUmjuiklATxvHtLD2-oJ7dj-UO-n4f/view?usp=sharing) for May 2020 recorded talk with [Dr. Richard Wardrop](https://www.umc.edu/som/Departments%20and%20Offices/SOM%20Departments/Medicine/Educational-Programs/Welcome%20from%20the%20Vice%20Chair.html) | ACP Module: [High Value, Effective Testing]() | | | | [Finding Health Care Prices Online](https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2663755?redirect=true) (10') |

Opt: Creating a Positive Culture for High Value Change\*

| Work on Final Project | | | | [The True About Generic vs. Brand-Name Medications](https://www.huffpost.com/entry/generic-prescriptions_n_6730194) (20') | | | | | | Peruse Rx-Financial resources \* | | | | | | Opt: [More on Pharma](https://www.nytimes.com/2020/01/31/health/pharmacists-medication-errors.html)\* | | | ### **Further Instructions & Resources**: * **VBHC Module Instructions**: * Focus on M6S9, where students simulate lowering costs for a theoretical patient. Have students be prepared to share what they came up with. * **RX-Lowering Activity** * Instructions: Please complete the prescription cost-lowering activity prior to the group discussion. Students will be asked to report on their findings from the activity. It's encouraged that students work together to divide the workload and discuss; however, please make sure each student looks at each resource presented in the assignment. {% file src="/files/-M8NGF-zqmhq1J3MoaNf" %} Cost-Lowering Activity {% endfile %} * **Session 5 - some instructions** * Facilitators can optionally create opportunities during the class discussion to group up students so they can practice high value communication strategies. This activity was very well-received by the UNC SOM students -- they wished we had devoted more time to it during the session. This activity has been pulled from the MedEd portal. Included is a pre-/post-survey for students to do on their own for their own self-enrichment, or class facilitators may choose to collect the responses to review. To read more about this activity and access the other resources, click [here](https://www.mededportal.org/publication/9894/). {% file src="/files/-M8NH7OVRYIW2WEay\_kQ" %} Pre/Post Survey - Optional {% endfile %} {% file src="/files/-M8NHCoLu87DeF-Cnxop" %} Role-Play w/ feedback form {% endfile %} * **Order Wisely Activity** * First, [this video](https://hvpaa.org/wp-content/uploads/2018/10/Borowitz_Low-Value-Labs.mp4) provides a short overview on how to determines at one's own institution what is a high- versus low-value lab practice and ways to potentially address over-ordering. * Request that students pick 4 videos (2 imaging and 2 Hospital Medicine) that interest them. They should be prepared to discuss what they watch. * Optionally, facilitators can choose to assign a component of this exercise as a Mini-Prez (note, students in the UNC SOM elective highly rated mini-presentations!) * **Opt: More on Pharma** * This NYT piece highlights the "pharmacy" side of the HVC prescribing discussion, as well as some of the challenges faced by pharmacists trying to meet the demands of their employers (e.g., quotas on refills, etc.). There have been some unfortunate consequences to quota-driven corporate policies. * Our Generic Drug Problem * Not to complicate things, but not all that's generic is gold. Out of some scandals surrounding generic drug production came [Valisure](https://www.valisure.com/about-us/). You can learn more in two podcast episodes featured in [The Peter Attia Drive](https://open.spotify.com/show/63AWQmsSnFNFHUqnRAOFtD?si=0iL8oLJLRWeZdK7XgpEhDQ). * [Interview with Katherine Eban on Widespread Fraud in the Generic Pharma Industry](https://open.spotify.com/episode/58tGzXNkph5sIvtYY3Bupy?si=GEgxBJBJT3Sp2HLHpGD29g) * More on [Katharine Eban](https://www.katherineeban.com/), journalist, & author of "Bottle of Lies" * [Interview with David Light, CEO of Valisure, on Zantac Recall](https://open.spotify.com/episode/7syLOUqQCrG2LbAKL8YYUZ?si=mpaJK2XURSKEP2gk_Tb_bA) * *Note: This interview is provided for the sake of completeness; it discusses the recall of Zantac due to its inherent molecular instability - not because of any foul play or fraud by pharmaceutical companies.* * **Peruse Financial-Rx Resources** * Ideally, students should become familiar with 1 - 2 of these resources and identify the ones that can be their “go-to” when in clinic. * [Healthcare BlueBook](https://www.healthcarebluebook.com/) * [UptoDate - Patient Education Tips](https://www.uptodate.com/contents/coping-with-high-drug-prices-beyond-the-basics) * [Beers Criteria Medication List](https://dcri.org/beers-criteria-medication-list/) (resource for prescribing in a geriatric population) * [STOPP/START criteria](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4339726/) (resource for prescribing in a geriatric population) * [GoodRx](https://www.goodrx.com/) * [MedStopper:](https://medstopper.com/about.php) Deprescribing Tool * [Costs of Care Affordability Accelerator](https://moonshot.costsofcare.org/) (learn how Costs of Care is convening experts to improve patient affordability) * **Opt: Creating a Positive Culture to Influence HVC Change (follow-up from Dr. Wardrop's talk)** * [**Why Culture Matters**](https://www.sciencedirect.com/science/article/pii/S2213076419302519?dgcid=author) * This article identifies organizational culture as a potential barrier to healthcare quality improvement. It provides several examples of why this might be true. Key themes addressed include patient safety, interprofessional communication, respect, and workplace diversity. * Residents' Self-Report On Why They Order Perceived Unnecessary Tests * Turns out that we have a lot of self-insight! This article highlights that residents recognize the moments their care decisions are not fully high value and what types of barriers contribute to the perpetuation of such action. * Harnessing Motivation * The authors delineate between intrinsic/extrinsic motivation and then describe the factors that help make those motivators successful. This article is included to emphasize how important it is to create environments that motivate physicians to perform. Additionally, it explains that these motivators can be unique to physicians and/or physician-groups. Featured vignettes illustrate how easily one could perceive that some change or another is a great idea and will bring about improvement, when the reality is the exact opposite. We must consider that context and reference points contribute to motivation; and if we don't keep these ideas in mind, we won't be able to set up systems that adequately support physician wellbeing and performance, as well as patient care. * Does Peer Pressure Increase the Rate of HVC in the Clinic? * This report shows how policy makers can harness the power of psychology to influence physician behavior. Specifically, this RCT demonstrates how peer comparisons helped improve the quality of care delivery by clinicians. * Taking action on overuse: Creating the culture for change * Again, organizational culture matters. Why? Culture is comprised of the shared values and norms within a group that can influence decisions made by a person, a team, or a health care system. Changing behavior is hard; and it's especially difficult without paying attention to and addressing culture. This article outlines an action plan for how one might begin to change organizational culture that results in medical overuse.The authors convened a multidisciplinary stakeholder advisory committee, reviewed social science theory and literature, studied both successful and unsuccessful attempts at improving high value care, and interviewed innovators from 23 organizations across the U.S.; and they decided upon four conditions for change that foster collegiality and collaboration across providers, providers and patients, and healthcare system leaders. * At the heart of the framework are conversations that lead to action and behavior change that slowly begin to shift the culture of how medicine is practiced. These conversations occur between clinicians, patients and team members and focus on evidence about the potential for patient harm, current rates of overuse, and patient [stories](/optional-deep-dives/untitled) about the consequences from delivery of an unnecessary service. * Four catalysts that support these conversations were identified: * Ensure consistent communication about low-value practices and how to address them * Build a culture of trust, innovation, and improvement -- foster a space that supports non-judgmental non-punitive conversations that are welcoming to innovators * Establish a consensus around shared language and purpose when discussing overuse. Our language carries emotional baggage; to bring about change, we might need to re-examine the ways we are talking about change. For example, perhaps this means we move away from the term "high value" and work towards "reducing medical overuse" instead. * Commit resources to measurement * How will providers know they are contributing to overuse? We need to present data that's meaningful and actionable. * You can assess your own organization's culture [here](https://takingactiononoveruse.org/), the accompanying website built from the work of these innovators. {% file src="/files/-M8lfRipwzdCfeLFhrhz" %} Residents' Self-Report {% endfile %} {% file src="/files/-M8aeUzoRuGc72pXfuX-" %} Motivation (Extrinsic/Intrinsic) {% endfile %} {% file src="/files/-M8ahpyKuItuy8s0bbaD" %} Peer Comparisons {% endfile %} {% file src="/files/-MAVgyh1d4GjvRAmm3EK" %} Addressing Overuse - A Framework {% endfile %} # Session 5 This section contains all of the suggested discussion questions for class meetings. **SESSION 5:** * **(5’) Welcome Back** \* * Students share any updates for the class; any comments lingering from the last session * Introduce the role-play exercise to students. \*Note at UNC SOM, students shared that they would have preferred spending a longer amount of time doing the role-play exercises versus discussions. * **(50’) Role-play** \* * There are two scenarios included in the activity. Put students into “Break Out” Rooms - ideally in groups of 3-4. * Groups of 4: Each pair role plays a scenario; the other pair observes and comments. Pairs switch. * Groups of 3: One person observes; two people get to role-play and then everyone rotates roles. * **(5’) Debrief (or you can work the debrief into the discussion on the modules)** * Questions to ask: * How challenging (or not) was it to have those conversations? * What strategies did you employ to discuss financial toxicity? * Were you able to ask screening questions successfully? * If patients had challenges understanding you, how did you switch up your communication technique? * What was your feedback, from the observer and from your patient? **\*(10') Break\*** * **(25’) Discussion on Module 6** * This module explores how medication non-adherence can impact health, reasons why patients typically do not adhere to prescribed treatment regimens (especially due to costs), and strategies for high-value prescribing, which aims to reduce medication cost and complexity to improve patient outcomes. * What are the individual and societal harms associated with medication non-adherence? * *This module discusses patients putting off needed care and/or other household needs (such as groceries) due to medication costs. For example, when patients cannot afford their medications, they often stop taking some of their medications or they resort to other behaviors that undercut the benefits of medication, such as skipping doses, splitting pills, delaying refills, and avoiding new prescriptions. This contributes to delayed diagnoses and inadequately managed chronic diseases, which increase the burden physically and financially for patients, as well as society as a whole.* * *From Module 6: “cost-related medication nonadherence is a common problem that leads to more frequent emergency department visits, psychiatric admissions, and nursing home placements, as well as decreased overall health status.”* * What are the barriers to discussing medication costs with patients? * *Examples include: time, taboo topic, strength of patient rapport (i.e., is this a new patient? Is this a patient you've seen before?), patient trust.* * Is it important that prescribers integrate questions regarding ability to afford medication when discussing treatment plans? * *From module 6: The majority of patients say that they would prefer to discuss the costs of medical treatments with their physicians ahead of time. Seventy-nine percent of physicians say they wished they could discuss costs but don’t due to time constraints and unease with the topic.* * *“More expensive medications often result in lower daily compliance rates (patients take the medication less consistently), which for certain medications results in worse patient outcomes. For example, in a study of more than 90,000 people taking statins, those who were prescribed generic statins had a better compliance rate, which results in an 8% reduction in incidence of death and hospitalization for ACS or stroke in that group.”* * *According to one study, when physicians and patients discussed costs, 41% of patients were switched to a lower cost medication (vs. only 12% of those patients who did not discuss costs of medication with their physicians.* * According to *Costs of Care*, what are some screening questions you can ask? * *When you take the medication history, ask patients:* * *Do your medications cost too much?* * *Have you ever cut back on medications because of cost?* * *Have you ever cut back on other things (e.g., food or leisure) due to high drug costs?* * What is the definition of high-value prescribing (as used in the module)? What is an example of a medication that is frequently prescribed inpatient but is often unnecessary when the patient is discharged? (PPIs for stress ulcer prophylaxis) * *“High-value prescribing entails providing the simplest medication regimen that minimizes physical and financial risk to the patient while achieving the best outcome.”* * *High-value prescribing is achieved by: 1) decreased costs; 2) decreasing complexity; or 3) decreasing risk of medications; ideally we aim to decrease all three simultaneously.* * What are the most effective strategies in lowering drug costs for patients? Have students talk through the GOT MeDS mnemonic. * *“GOT MeDS” mnemonic:* * ![](https://lh4.googleusercontent.com/9Fx3_P10lhXAJPEUwRQ0skewdm5SfizlNqEb3pUsBsszfEukPDyRoozmHWxaJMGhYiG0nqBk7tuqNRVSyiEmN-ksXlwwAvKvSMGfDMuzgyEg4LwGft9ytU3CRpSE34SoEfzd4WVZ) * At the end of Module 6, you helped lower the medication costs for a hypothetical patient. You also practiced in the activity posted on Sakai. Could you see yourself using these same strategies in your practice? Why or why not? * *Call on students to share what they found in the Module 6 Section 9 Rx lowering activity and the Rx lowering activity that we created.* * **(25’) Discussion on Module 7** * This module explores the pitfalls that can occur in clinician-patient communication and techniques for improving communication. Learners explore models of communication, including Cleveland Clinic’s communication program. * We'd like to get an understanding for how helpful you found this module about communication. Was it eye-opening? Are the recommendations helpful? * *Medical school teaches us the value of iteration - repeating and relearning over and over again. That is why we think this module is particularly important. But if you were designing this course or if you were to redo these modules, at what point would you think this training to be useful?* * Is it helpful to have these reminders every once in a while? * Students should share examples of both good and bad physician-physician and physician-APP communication. * What seem to be the most common pitfalls in clinician-patient communication? * *Note: The Story from the Frontlines video in Section 2 and the podcast in section 3 feature Dr. David Ring and Dr. Maggie Lowenstein discussing pitfalls: “Conversations about value constitute some of the most challenging discussions we have,” Dr. Maggie Lowenstein wrote in an article for JAMA Internal Medicine (as read in module 7, section 3). “Part of the struggle comes from explaining complex concepts such as the harms of overdiagnosis and overtreatment. However, the truly difficult task is breaking the news that medicine is imperfect, and we don’t have answers to every question. As a young physician, I work hard every day to gain patients’ trust. I worry that admitting the fallibility of my profession will be conflated with inexperience, my hard-earned trust will be lost, or worst of all, my patients will feel that I have abandoned or failed them.”* * What is a communication skill or tactic that you took away from this training that you would like to try with your patients? Discuss takeaways from *Costs of Care*, too. * *The module provided the following tips for effective communication:* * *Begin with active, empathetic listening;* * *Get to know a few things that make that person special;* * *Elicit patient beliefs and questions;* * *Summarize and legitimize their concerns;* * *Use non-technical language and pause for questions between points;* * *Focus on creating a partnership;* * *Have “scripts” for common scenarios, e.g.: patients seeking antibiotics, patients with limited life expectancy, and patients with pain seeking pain meds.* * *Module 7, Section 4 also includes a table of common words/phrases that are used in medicine (such as “patient refused”), potential pitfalls (e.g., “Establishes decision- making divide (subtle or overt) between patient and clinicians”), and proposed alternatives (e.g., “Patient declined,” or “Patient preferred not to/would rather not.”)* * Would you be willing to try writing “SOAP-V” notes during your rotations? Why or why not? * *Might be an opportunity for clinical students to share their experiences writing notes for their preceptors. Did they think they had enough experience to really comment on the value of the care?* * If you have preceptors/professors helping to facilitate, ask their opinion of the SOAP-V. * Review the tools discussed in “Section 7: Partnering with Patients.” What do you think is the most effective way to help patients to be partners in their treatments? * *(1) Prompt lists, such as CW’s 5 Questions to Ask your Doctor* * ![](https://lh3.googleusercontent.com/P4f_7tXsDDx4-UqsOAMJm6JYmCU7bFv3ligq9Q_VrHsN9h7tfUMtxhFOE_U-So1U5O7Zx0Cy_SM6_xrdBW09neam2U_tNcinbnf3uqgCLwQo_6Uk8wMcBmJwndyH2R9LV8aVH24S) * \_(2) Decision Aids for choosing treatments: ; * *(3) Motivational Interviewing:* [*https://www.ncbi.nlm.nih.gov/books/NBK64964/*](https://www.ncbi.nlm.nih.gov/books/NBK64964/) * *(4) Teach Back:* [*https://www.ahrq.gov/health-literacy/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool5.html*](https://www.ahrq.gov/health-literacy/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool5.html) * **(5') Wrap-up** # Session 6 This section contains all of the suggested discussion questions for class meetings. * **(5’) Welcome Back** * Students share any updates for the class; any comments lingering from the last session * **(60’) SME Speaks + Q/A** * Dr. Richard Wardrop shares his perspectives on ways to imbue high value care into your own practice and into that of your team. He shares strategies for identifying and understanding your institution's culture, why culture matters if you want to make high value care changes, and how through meaningful engagement with your work, your colleagues, and your patients you can reject burnout and find professional and personal fulfillment. Super inspiring talk! Finally, he also discusses how he and a team were able to quickly deploy a high value strategy for conserving their blood donation supplies during the COVID pandemic. **\*\*(10') Break** * **(30’) Debrief on Ordering Wisely Activities // Mini-Prez** * What are the steps to developing a HVC lab project as described in the Borowitz talk? * *Figure out what you want to accomplish* * *Pick targets - talk to colleagues/Choosing Wisely* * *Figure out if you have a problem - there are lots of things to do but not all are relevant to your institution* * *Have access to the EHR* * *Where is the problem so you can engage the right stakeholders* * *Decide on your outcomes* * *I.e., Saving by Decreasing Volumes* * *You & stakeholders have to know the difference between costs/charges* * *Rare interventions affect labor or instrumentation* * *Be aware of hidden costs* * *Downstream effects - these can be different to measure* * *Plan your intervention* * *Get buy in from stakeholders* * *EMR based interventions* * Round-Robin style, students share a few things they learned from their selected videos * Among the resources provided, which do you consider most useful? Which would they integrate into their practice? * **(15') Prescription Lowering Resources:** * What are some of the tips suggested by the Patient-Education Tips (UptoDate article)? Prior to talking to doctor, teach patients to... * *Create a medication list and to ask about lower-cost alternatives* * *Ask their insurance company about lower-cost alternatives* * *Shop around and find the lowest prices* * How would you want to share these tips to your patients? * How do you feel about the onus being on both the patient and on the provider to ensure medication adherence? * Did you find a HVC prescribing resource that you prefer to use? * Did you try the MedStopper tool? * **(5') Wrap-up** # Overview Improving Value in Systems ![](https://649813981-files.gitbook.io/~/files/v0/b/gitbook-legacy-files/o/assets%2F-M7M_c6YurD-Y3nCgs9N%2F-M8RzxiVQTn-MyaU3UkY%2F-M8Rzz6V7W3B_S3JWqqe%2Fimage.png?alt=media\&token=63522df7-6097-430d-a4be-7578b6bec4bd) # Assignments Week 4 ## **Syllabus** | **Monday** | Tuesday | Wednesday | Thursday | Friday | | ------------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------- | -------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | VBHC: Mods 8/9 (2˚) |

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| Optional: Closing Session (1˚) | | [Penn Medicine Nudge Unit](https://vimeo.com/244833610) | Work on Final project | Opt: Reality: How We are ID'ing Quality Measures in Practice\* (PDF below) | Click [here](https://drive.google.com/file/d/1gpHR89hIaqenT9dUAvnY9JPRF3d6si2Z/view?usp=sharing) for May 2020 recorded talk with [Dr. Mark Gwynne](https://www.med.unc.edu/fammed/directory/mark-gwynne-do/) | Final Reading: HIGHLY ENCOURAGED [Dr. Sachin Jain's HVC Takeaways](https://www.forbes.com/sites/sachinjain/2020/05/23/12-unsettling-lessons-learned-trying-to-make-healthcare-better/#527684dc61ea) | | Mini-Pres: Capitation vs. Bundled Payments\* | Opt: Back to Narrative Medicine & the [Power of the Story](https://ssir.org/articles/entry/using_story_to_change_systems#) \* | Opt: Recent Insights into Bundled Payments\* | Submit Final Project\* | | ### **Further Instructions & Resources**: * **Mini-Presentation: Bundled Payments vs. Capitation** * This week's modules explore some large-scale strategies for reducing healthcare waste. In previous weeks, we touched on the concept of "alternative payment models"; this week, we are going to look into them further, starting with the overview from the modules and concluding with an exploration of what's happening locally at UNC. In between, we ask that you become more familiar with these two larger models -- capitation and bundled payments. Provided are two HBR articles, one on capitation and one on bundled payments. Alternatively, you can swap out the bundled payments article and watch the interview with Porter and Kaplan, which is very good and gives a great breakdown of both models. * *All students:* Please be prepared to discuss which you think is more feasible AND which model you'd prefer to work under. Soon we will all be applying to residency -- how much does your future institution's financial structure matter to you? Will it influence the programs to which you apply? * *Mini-Presenters:* Provide an overview of the payment model to which you've been assigned. How does it work? What are challenges to implementation? Where has it been successfully implemented? What makes the model ideal (or not?) Do you believe it's feasible to see healthcare systems adopt this model? What are some considerations for health system leaders? {% file src="/files/-M8ld3Hb946FUUDxDSN3" %} {% file src="/files/-M8ld8wkWLIglES5Tr6w" %} [Interview with Porter & Kaplan](https://hbr.org/webinar/2016/06/the-case-for-bundled-payments-in-health-care) * **Opt: Back to Narrative Medicine and the Power of the Story** * A few weeks ago, you had to the option to dive deep into the principles behind the emerging discipline, narrative medicine. Much of what narrative medicine focuses on -- listening to our patients, retelling their stories in compassionate ways, creating treatment plans that consider what's important to them -- parallels with the goals of high value care. In her article, writer Ella Saltmarshe revisits the idea of the story; how sharing narratives and experiences shows itself to be a powerful mechanism for bringing change at the macro level. She describes how stories as "light...glue...\[and] as web" can be used to change systems. * How does this idea resonate with you? (As we know, 3rd year clinical rotations requires applying our foundational knowledge with real clinical medicine; and we realize how much we start understanding medicine when we have our stories of patient care to fall back on). * How can we take our patient stories and effect change on a larger scale? (Some ideas for group activities include "Story Slams"; see Dr. Wardrop's 2020 lecture, Week 3). * Another point Saltmarshe brings up: we must highlight the work of mavericks, pioneers, etc. See Session 8, "Lead From Where You Stand." This is why it's important to identify and appropriately recognize HVC champions! * Stories can help us heal wounded communities; understand others and ameliorate the inequities that plague us. How can we understand our experiences with patients, their narratives, and build a new more equitable healthcare future? * **Opt: Reality: How We are ID'ing Quality Measures in Practice** * Knowing that shifting to a value-based system creates much administrative burden on physicians, these researchers set out to look at the quality measures collected and maintained by the CMS and how much the agencies have invested in them. Notably, CMS has created a ton of quality measures but only implemented 34.8% of them. Additionally, there's evidence to suggest that coupling payment to quality measures leads to some unintended consequences. This is a really timely piece and gives another dimension to our talks on value. {% file src="/files/-M8qNm26KdYu57pe2WaV" %} CMS Quality Metrics {% endfile %} * **Opt: Recent Insights into Bundled Payments** * The recent review looks back at various studies to ascertain the value impact made by three CMS bundled payments programs, Acute Care Episode Demonstration, the voluntary Bundled Payments for Care Improvement initiative, and the mandatory Comprehensive Care for Joint Replacement model. Their results suggest that bundled payments are helpful for mitigating cost/improving quality in joint conditions but not others. A few themes to think about: * What are the ways these programs were evaluated for Quality? * How was health care spending quantified? * What were the limitations of this review? What's the impact of these limitations? * What are the policy implications as listed in the discussion? {% file src="/files/-M8qKsAT-teC05qBK8bp" %} Impact: Bundled Payments {% endfile %} * **Final Project** * At UNC, students submitted their final projects to our online course program Sakai and then used the embedded commenting system to critique each other's work. * Student feedback from the course requested that final projects be submitted earlier, with presentations integrated into the course itself. * We encourage facilitators to make the decision that is best for their students and course objectives. # Session 7 This section contains all of the suggested discussion questions for class meetings. * **(10’) Welcome Back** \* * Students share any updates for the class; any comments lingering from the last session * **(45’) Discussion on Module 9 - recommend that discussions begin with mini-presentations on Capitation vs. Bundled Payments -- debates are encouraged! Below are some questions to foster more discussion** \* * Module 9 reviews different payment models, which Dr. Gwynne should be expounding upon in his lecture. * Mini Presentations on Capitation vs. Bundled Payments * Review of Bundled Payments (to be done via Mini-Prez): * Five conditions that must be met: * ![](https://lh4.googleusercontent.com/Y-IsJlraaohgO2Ko7kGP6kCT6ZsZtNGdAHMISB8F4JvRSBbZ2lYZM18Pu4RanUmXKgBwOp4ss7Y6_JqQ1cBGQKTJzbduPRCtEsP5ofqPW2WOaku0I5ufMS3A2e3UnJBesjycRVmL) * What’s a potential way that bundled payments might not be effective? * *Providers could try to offset price decreases with volume increases.* * Review of Capitation * *Providers receive a fixed per person payment that covers all health services over a defined time-period* * Review of global payments * *Global payments are extremes of capitated payments where a fixed payment is made for all services for a specified period of time, usually a year.* * Review of ACOs * *A combo of capitation and FFS where a group of doctors and other providers voluntarily come together to provide care for Medicare patients. Care is coordinated.* * It's key to keep in mind that capitation and global payments are more population-focused; that is, they are comparing patient outcomes to that of a population at-large which isn’t necessarily something that patients weigh heavily. * Precision Benefit Design (Value-based insurance design) is a way to change payment at the level of the payor, where there’s cost-sharing on high-value practices and low-value services would cost more to the individual patient. * The following question might be challenging for clinical students to answer; however, this is also an opportunity for attendings and/or others to chime in. In what ways have you ever felt incentivized to provide lower- value care (e.g., repeating tests; ordering unnecessary tests, images, or screens, etc.)? In what ways have you ever felt de- incentivized to provide low-value care? * *In Module 9’s Story from the Frontlines, the resident and medical student from the Module 8 discuss the migraine patient’s negative CT-scan results. The med student admits that, though unnecessary, he probably would have ordered the test as well just to be safe. The resident is upset because this woman has now been unnecessarily exposed to radiation and charged for the CT when it wasn’t beneficial for her health or presented concern.* * Think about the different payment models discussed in this module: Pay-for-performance, bundled payments, capitation, and global payments. If your organization were looking into changing its model, which would you advocate for? Why? What do you see as the potential barriers and pitfalls in this adoption? * Does anyone in the group already work or have experience in an institution with a payment model other than fee-for-service? Ask them to expand upon this. * What speciality are you thinking about going into? If your organization were to adopt value-based models, what specific effects might it have on your processes within this specialty? Do you think that overall, it would change the way that you practiced? **\*\*(10') Break** * **(45’) Discussion on Module 8** \* * Ultimately, making systemic change hinges upon the responsiveness of those around us. As medical students, we get thrown into different micro-cultures all the time, whether through our volunteer experiences, or on the wards rotating on different specialties. For this first part of the discussion, we will reflect on the cultural practices we’ve experienced or noticed, we’ll learn from faculty, and we’ll review the mechanisms of initiating change (i.e., Nudge unit). * Clinical students: discuss the differences in cultural practices you saw between the different specialties -- are you optimistic that the overall system can see broad change? * Non-clinical students: share an experience outside of medicine where the “culture” was particularly toxic, or not. These experiences could be in the context of school, of sports teams, of other work experiences or volunteer positions. * Module 8 discusses the power of the story to bring about change. Since this is the last week of the class, we can do a throwback/recall exercise - what story was most impactful to you? As you look back on the past few weeks, was there one story that stood out? * The number one contributor to health care waste is unnecessary services. As the Module 8 video explained, wasteful practices are often culturally perpetuated. What low-value practices have you seen in the environments you’ve worked in that could be attributed to culture? How did you find yourself responding to these practices? (For example, at UNC, we talked about the 2 units of blood being transfused nonsensically - what do you think this says about the culture? What does it say about the people who realized this cultural practice was futile?) * *The Module 8 Story from the Frontlines explores the tensions between best practice and established culture. It depicts a woman presenting to the ER with symptoms both a resident and attending diagnose as a migraine. The attending tells the resident to order a CT, though this isn’t best practice for a migraine and probably won’t serve the patient’s interests.* * Do you think all cultural practices that contribute to low-value care can be overcome? What are some barriers to changing aspects of culture? * *Barriers discussed include hierarchies, institutional inertia, and siloes.* * How do you think you can apply some of the frameworks or lessons from this module to help lead cultural change in your primary clinical environment? * *Frameworks and tools that were presented include the High-Value Care Culture Survey (HVCCS) which defines four domains of a high-value culture (Leadership and health system messaging; data access and transparency; comfort with cost conversations; blame-free environment), Kotter’s 8-Step Model for Change, and the MacColl Center for Health Care Innovation’s framework on creating the conditions for change.* * Dr. Moriates talked about a time in his residency where he saw a change unfold at his institution, thanks to the work of one attending physician. What are your thoughts on the power of One to change the institutional culture? If you’ve been on clinical rotations, have you seen exemplary leadership from your attendings or residents? * Module 8 discussed “nudge” theory and the potential effects of increased transparency with peers regarding patient care decisions. If your goal was to decrease unnecessary testing in your clinic by 10%, how would you go about this? Do you think that adding a justification step to EHR notes might aid in this? Would this impact your own test orders? How should you plan for and test this theory? What are some other ways this decrease might be achieved? * *Nudge theory posits that the framing of information will lead to different results, and that one can achieve desired results through appropriate framing. Research has shown that individuals are more likely to do something if their peers are doing it or if they know that their peers will be impacted by or judgmental of the individual’s actions or lack thereof.* * *Examples are: handwashing adherence rises if people are told not doing so will lead to others getting sick, but not when told that they themselves may get sick. In a non- medical sense, taxes are paid more often when people are told everyone else pays their taxes, but not when people are told the benefits or consequences associated with paying/not paying taxes.* * **(10’) Wrap Up** # Session 8 This section contains all of the suggested discussion questions for class meetings. **SESSION 8:** * **(5’) Welcome Back** * Students share any updates for the class; any comments lingering from the last session * **(60’) SME Speaks + Q/A** * Dr. Mark Gwynne, Associate Professor and Medical Director for UNC Health Alliance, talks to the class about alternative payment models at UNC and the need for a culture shift to truly bring high value change to the healthcare system. \*\***(10') Break** * **(20’) Discuss Module 10 - briefly** * The course builds to this final module. Up to this point, we've learned to define value, to measure value through PROMS, to effectuate change through our bedside practices (i.e., high value prescribing), and how our systems can encourage high value medical practice. One of the ways to begin implementing such change is to determine through rigorous evaluation the practice areas (i.e., testing, diagnosing, communication practices) that yield little to no value, hypothesize solutions, act on those solutions and iterate. Again and again. Quality improvement processes help us through this process; and this module introduces various methodologies we can use. * Of the ways that we can carry out QI projects, was there a particular methodology that you liked the best? * If you’ve done a QI project in the past, describe your process. * ![](https://lh4.googleusercontent.com/Jp_e5dEnx6wlrrEqH86jIMzWAm7qAP8JPqhZ6Z2ShHEe6nXgGiQ0JGRnnW14BPMAEqWqK4z_BNJDDVRQDBamcHF4XNk30n4CQNenpqVANe4idJzL3oCY7JtbdP8e4Y2JIPPclbHt) * ![](https://lh6.googleusercontent.com/tZuZAWbfF0bd4crgqHsKVaQVu-NBvwgKfmZOEOhqZ3rmRDmPELyY2-y4j1iksw86tRe8a4xn-YGXpbrUoqNu9poGKiaYdnkcXe8JYwaawi0Vx6Yxty7IG5EMG1iccMy9z5jmw78Q) * ![](https://lh3.googleusercontent.com/TkW5MGccLEx3K-EqwAocjfsfXG-4M47QXC3UJh71CGU_Ps50ibjX6iAtBEZfTXK-btWG-WYlew5FzG88GV2JAQHcDqID3gsGHRysUoxeOk7VdKzO1H8yVvlXIg9_4fgO1xxNL4CE) * ![](https://lh3.googleusercontent.com/RHseDnbU5lityWFyF5ws5vYOEU9Wa5X1DcXwKXqISt7-7F9pyNVqnJormhC7ytJPOvsaHdJ_RKMSrQOcxAs5QWX-w16QEzkBr9YZ1DRKHfDf7aWeF0PZIL1LPtc_BGWzreao0GBg) * This module covered SMART aims – goal statements that asked the learner to state their goals so that they are Specific, Measurable, Achievable, Relevant, and Time-bound. Together, make a SMART goal that is specific to this group of learners (if you are working with early health professional students, you could choose a goal that has to do with their own lives rather than a clinical or health systems science example). * Then, based on the tools introduced in this module to plan and implement changes, discuss how this aim might be achieved. * *The recommended tools are process charts, fishbone diagrams, pareto and special cause variation charts for understanding problems and monitoring results of implementations; using the COST framework (Culture, Oversight, Systems-change, Training) to identify barriers to and supports for implementation; laying out steps, roles, and responsibilities in a project charter; and measuring/monitoring results by identifying and gathering data and creating statistical process control charts etc.* * This module discussed how the Lean approach to achieving better outcomes in health care focuses on reducing and eliminating waste from processes. In small groups, identify the areas in which learners see the most waste, and choose one. Define the processes that surround this issue. Choose one process and define how it should be changed based on which steps contribute to waste. Tailor this to the audience; if first-year medical students, you may want to remain as a large group and discuss areas of waste they perceive in health care through their academic or personal lives and discuss what processes likely contribute toward these. * *Module 10 discussed utilizing process mapping to define process steps and stakeholders in order to identify where processes become inefficient, break down, or aren’t staffed appropriately. Mapping a process by its steps can help to illuminate where it needs to be improved.* * **How Can You Lead from Where You Stand? (and Course Feedback)** * (Note: At UNC, we ended up creating a separate class session that was devoted to final debrief) * Topics to discuss: * How as students (or clinicians, residents, etc.) we can bring change to the teams we work on? * Some ideas: * Communication strategies; introduce Choosing Wisely; Choosing Wisely badges; identify HVC champions * Create interest groups, journal clubs, events * Curricular changes * Course feedback * Don't forget to send out the post-survey! # Final Project Ideas generated from the Inaugural Class at UNC School of Medicine Students generated a ton of amazing ideas for their final project. The parameters were deliberately vague, asking students to reflect on low value care they (or a family member) witnessed or experienced and innovate a solution that improves upon that care experience. Ideas ranged from narrative reflections, to creating new clinics, to critically evaluating existing programs that target the same or similar issues. Optionally, you can choose to have students submit their final projects earlier in their course to allow for more class discussion and debrief time. Here are some of their project titles: * Narrative Reflection on Low Value Care Experience as an Undergraduate Student * An IPU Approach to High Value Care for Women Experiencing Endometriosis * A Value-Based Approach to Opioid Use Disorder via PCMHs and MAT; spotlight on local program [Project CARA](https://mahec.net/patient-information/ob-gyn-care/project-cara) * Ideas for Implementing High Value Care principles into the Undergraduate Medical Curriculum * Initiatives for Improving Patient & Provider Health Literacy * Addressing Timely Psychiatric Care in North Carolina EDs; critical evaluation of [NC-STeP](https://www.ncdhhs.gov/divisions/office-rural-health/office-rural-health-programs/statewide-telepsychiatry-program) * Tablets as Replacement for Premedications in Pediatric Preoperative Care # Equity & HVC Critical to delivering high value care is understanding that it is not just about reducing costs. Instead, it's about ensuring that your treatment plan (and understanding of the problem) is tailored to the patient and what is important to them (i.e., PROMS). Shifting to a value-based system and focusing exclusively on cost (which of course is a fundamental element of VBHC) could potentially lead to worse outcomes for our most vulnerable patients. We need to guarantee that our value-based practice models are responsive to diverse patient needs. The patient always comes first. {% content-ref url="/pages/-M7n1xDFqXVA7BQS2jAt" %} [Assignments Week 1](/week-1/assignments) {% endcontent-ref %} # Narrative Medicine & HVC What is narrative medicine? How can instruction in the humanities inform medical practice? What role does narrative re-telling play in healthcare reform? These assignments offer opportunities to learn about narrative medicine and investigate whether it could impact our understanding and provision of high value care. {% content-ref url="/pages/-M7n1xDFqXVA7BQS2jAt" %} [Assignments Week 1](/week-1/assignments) {% endcontent-ref %} {% content-ref url="/pages/-M8S3Pq\_qKaZT61ExGOl" %} [Assignments Week 4](/week-4/assignments) {% endcontent-ref %} # Hot Spotting & Value Stewardship This Deep Dive presents different opinions on "how we got here," i.e., what *really* contributes to our high health care expenditures? (Spoiler alert - probably a combination of lots of forces...) Read more articles by Dr. Atul Gawande, and critically evaluate his arguments in light of the Gaffney reading (assigned for Monday, Week 2). Additionally, reflect on the true power of hot spotting programs. {% content-ref url="/pages/-M7spNKH\_MNkCiXS9TwJ" %} [Assignments Week 2](/week-2/assignments) {% endcontent-ref %} # Pharma & HVC Pharmaceuticals play a HUGE role in medical care, and responsible prescribing is a critical component to value-based medicine. This Deep Dive explores this industry -- a key partner in health care delivery -- and some of the hurdles that must be overcome in order to ensure we are giving the right drug to the right patient at the right time. {% content-ref url="/pages/-M8NAbc0vypAj0sFZpKb" %} [Assignments Week 3](/week-3/assignments) {% endcontent-ref %} # Organizational Culture & HVC High value care reform is only as good as its team. Why? How does an organization's culture impact the care that's delivered? This Deep Dive expounds upon this concept and hopefully, encourages students to think critically about the institutional culture in which they find themselves as well as identify what's important to them as they begin thinking about residency and beyond. {% content-ref url="/pages/-M8NAbc0vypAj0sFZpKb" %} [Assignments Week 3](/week-3/assignments) {% endcontent-ref %} # Quality Control Many organizations are making the transition from volume- to value-based reimbursement. We learned in the Dell Modules that central to this transition is identifying ways of evaluating it; and we discussed PROMS as the most impactful way to ensure that medical care is highest value. How are we doing in 2020? This Deep Dive aims to shed light on CMS's role in identifying and implementing quality metrics. {% content-ref url="/pages/-M8S3Pq\_qKaZT61ExGOl" %} [Assignments Week 4](/week-4/assignments) {% endcontent-ref %} # Reality of Bundled Payments We learned that "bundled payment" reform can be an impactful way to bring high value care to health systems and to patients. As discussed in the Dell Modules, CMS began implementing some bundled payment options; this article is a follow-up to that move and critically appraises them. {% content-ref url="/pages/-M8S3Pq\_qKaZT61ExGOl" %} [Assignments Week 4](/week-4/assignments) {% endcontent-ref %}