Session 2
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 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.
                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.
            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,
          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.
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