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Foreword – Robe..
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Robert M. Wachter, MD

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Professor and Associate Chair of Department of Medicine, University of California, San Francisco

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A couple of years ago, I was speaking to a group of medical students at my institution, the University of California, San Francisco. The setting was a small seminar, and we were running through a variety of topics related to health policy. The students asked me about the changes I'd seen over my 30 years of clinical practice, and where I saw the healthcare system headed during their professional lifetimes. I decided that this was a great opportunity to shake them out of their youthful complacency.

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“You folks need to be prepared for a career that will be massively different from mine,” I said. “You will be under relentless pressure to deliver the highest quality, safest, most satisfying care … at the lowest possible cost.” I spoke these words slowly and solemnly, my words heavy with gravitas.

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After a few seconds, one of the students raised his hand and asked a question that was at once naïve and profound. “What exactly were you trying to do?” he said.

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I think of that student's question every time I consider the state of our healthcare system. Today's clinicians and administrators may be unsettled, even overwhelmed, by all the pressures they now find themselves under to deliver high-value care: more stringent regulations and accreditation requirements, public reporting of various value-related measures, value-based purchasing initiatives, new payment models such as bundling and accountable care organizations, even Yelp reviews and apps that offer cost and quality data with a single click. It's certainly a lot to take in. Yet what is odd, even bizarre, is not that we are now under such pressure. What is odd is that, until recently, we were not.

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The indictment against our healthcare system—particularly the American system, though other countries' systems are facing similar pressures—is well known and largely accurate. Evidence accumulated over the last generation finds that we do poorly on virtually every measure of healthcare value. Variations are enormous and clinically indefensible. We deliver evidence-based care only about half the time. Medical errors are rampant, and tens, perhaps hundreds, of thousands of people die each year from preventable harms. Patients are frequently unhappy with their care, usually with justification. Access is sporadic and unpredictable. And if all of that weren't bad enough, the costs of care are bankrupting the government, and, increasingly, corporations and individuals, too.

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The field of patient safety has taught us that most errors are committed by good, competent people working in dysfunctional systems. And so it is with healthcare value: while there are certainly instances of low-value care delivered by clinicians who are incompetent or even dishonorable, most low-value care is delivered by good clinicians working in dysfunctional systems. Here, of course, I'm not simply referring to the healthcare delivery system, such as clinics or hospitals. Just as important are the systems that determine the environment in which care is delivered: the system of training young physicians and other clinicians, the system of capturing key data and making it available to both clinicians and patients at the point of care, the system of regulating medicine, the malpractice system and, of course, the payment system. In light of this overwhelming complexity, efforts to improve value need to be broad-based, innovative, and interdisciplinary. Moreover, such efforts involve knotty measurement problems and often profound ethical and political ones. This means that there will not be a magic bullet for improving healthcare value, no healthcare value checklist.

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Which is where this book comes in. As the authors note, there are other resources focusing on the individual elements of value: cost, quality, access, patient safety, and patient experience. And there are books that explore many of the contextual determinants, such as the payment and regulatory systems. But, until now, there has not been a single book that brought together each of these domains in the service of helping clinicians and non-clinicians understand and improve healthcare value.

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The authors have done a masterful job in weaving together the appropriate resources and educational techniques. There are case studies to illustrate key points. Foundational information, such as the nuts and bolts of health insurance or of costs and charges, are presented at the level of detail needed to understand these topics, while skillfully avoiding the temptation to wander into some very tall weeds. Charts and graphs help illustrate key points. The book is written in a style that manages to be both authoritative and utterly accessible.

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Perhaps most impressively, the book is deeply practical. The authors have unmatched experience implementing programs designed to improve value in their own institutions, and in many others across the country. In sharing these experiences, they manage to draw universal lessons that will be helpful to everyone—from the young clinician-educator trying to teach her students about value, to the practicing physician, nurse, or pharmacist beginning a value-improvement program, to the healthcare administrator or policymaker trying to understand this vital new agenda. Given the complexity of the topic and the diverse needs of these audiences, this is a singular achievement.

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For those of us who work in, or care about, healthcare, improving value is the defining issue of our generation. This is not simply an academic matter, nor is it one whose impact is limited to the healthcare system. Yes, high value in healthcare is about whether a woman's breast cancer is treated effectively and compassionately. And it's about whether a child can see the right provider to get her vaccines and treat her strep throat. And it's about whether an elderly man with angina receives the appropriate medical therapy and does not receive an unnecessary stent.

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But as healthcare costs crowd out other national priorities for societal spending, high-value care is also about whether our schools have enough teachers, our streets have enough policemen, and our businesses have the resources they need to compete in a global market—while still providing excellent care and maximizing the health of the population. It is not hyperbole to say that the healthcare value agenda is about the overall viability of our civilization, and the preservation of our way of life.

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Remarkably given the importance of this issue, until now, we lacked a roadmap to attack it. With this book, we now have one. That makes it essential reading for everyone who cares about making our system better.

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