We hope that everyone with a stake in making healthcare delivery work better will find this book useful. That being said, we wrote it with a primary audience in mind: the people who spend their days (and nights) caring for patients. At the beginning of the 21st century, healthcare professionals are able to deploy an extraordinary range of medical capabilities. The problem is that sometimes our capabilities stretch beyond what we are able to afford financially, physically, and morally. As the adage goes, just because we can do something does not always mean that we should do something.
The irony of our modern predicament is that even as scientific knowledge and technology have enhanced our prowess in some ways it has actually added to our fallibility in others. Healthcare has gotten more specialized, more nuanced, more complicated. Where complexity exists, so do opportunities to mess up. As a result, for those of us on the frontlines, applying our capabilities appropriately is increasingly becoming an uphill struggle.
For patients, our misfires can be devastating. Every day, patients are blindsided by bankruptcy-inducing medical bills. Every day, patients are subjected to intensive end-of-life treatments that overlook the fact that most people have other goals besides simply living longer. These occurrences are seldom flagged as “medical errors,” but they still represent significant harms. In many cases these harms can be avoided, not by passing legislation, but by improving our processes of care.
This book is an extension of that insight. It is not an introduction to healthcare policy. It is not an introduction to healthcare economics. It is not an introduction to healthcare finance. Those books already exist. We are instead focused on value-based care—the idea that healthcare needs reform not only in the halls of government or the suites of executives but in the wards and clinics where care is provided. Value-based care requires that those of us who care for patients optimize healthcare outcomes while also taking direct and specific responsibility for costs and patient experiences.
Parts I and II lay the groundwork for understanding value-based care by identifying several failure points in the clinical environment. We discuss why healthcare pricing is opaque (Chapter 3), and what this means for how we define and measure value (Chapter 4). We discuss the unconscionable disparities in how healthcare resources are distributed (Chapter 7) and how inadequate investments in primary care (Chapter 9) restricts access to basic services. We then talk about what these failures mean for frontline clinicians—the implications of being faced with too much to do in too little time, all while balancing discomfort with uncertainty, fears about malpractice, and concerns regarding fulfilling patient expectations (Chapter 10).
Then we talk about what we can do about it. We can supply a pipeline for change by embedding the principles of value-based care into the apprenticeship of health professional education (Chapter 11). We can improve patient experiences by tracking patient-reported outcomes and engaging in shared decision-making (Chapter 12). Sometimes, improving care is just a matter of choosing our treatment options more wisely (Chapter 13). In other cases, there are opportunities for us to be on-the-ground leaders of change within our own practices or institutions, developing projects and programs, and redesigning care pathways (Chapter 16).
Some of the concepts in this book are relatively new and others are surprisingly old. Nonetheless, efforts to embed them into the practice of healthcare remain at the earliest stages. That is where you come in. It is not enough to have a healthcare system that is capable. We need to have a healthcare system that performs. We need to have a healthcare system where those who spend their days and nights caring for patients are leading from the front rather than trailing from behind. If you are reading this, we know you are up to the task.