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by Jim Massey
Published on July 23, 2017

Today in the Gulf states we have high quality public health services funded by the state backed up by private health providers, most private healthcare is delivered as fee-for-service. In the private sector the physicians and hospitals are paid based on the number of health care services they deliver, such as tests and procedures. This has meant that there is no incentive to minimize the number and complexity of the tests ordered by the physician or ensure that they are appropriate and necessary. Until recently few lucky expatriates had comprehensive health coverage, and the premiums were set to cover this regime. Payment bore little relationship to whether your health improved or not. Now, with the introduction of mandatory health insurance this is changing, both public and private health care providers must justify the care being given and quickly and accurately submit their claims to realise the revenue.

The move to a clinically driven revenue cycle management system means that providers need a robust, enterprise wide electronic health record to submit accurate, timely claims. Luckily this change has coincided with the introduction of electronic health records across the region, however there is cost associated with tier 1 eHR implementations.

This new regime means the prescribing and ordering behaviours of physicians are now under more scrutiny than ever before. Once these changes settle down and the claims paid are matched to the diagnoses and the treatment received, the region will also have to move towards value-based health care based on health outcomes rather than the current fee-for-service.

So, everyone in the region is talking about value; what it is, how to measure it and what it means to the individual actors within healthcare provision.

The eHR vendors, including Cerner, are trying to show value to the C-suite, which naturally focusses on time and money, however the IHI1 introduced the Triple Aim in the USA, now generally extended to the Quadruple Aim, which I believe is the essence of value today, covering all the actors on the health care stage from patient to C-suite. The four aims are:

  1. Improving the patient experience of care (including quality and satisfaction);
  2. Improving the health of populations;
  3. Reducing the per capita cost of health care; and
  4. Improving staff engagement and retention.

It is relatively easy to measure the per capita cost of health care, where the value is recognised in dollars, but the other 3 aims are more difficult to assign value to and create measurements for, as the aims are intangible, different and sometimes contradictory2 depending on who is perceiving the value, and so are difficult to measure.

There are many different health care systems around the world based on different political, economic and social factors, so what is seen to have value in one system is different in others, it is not possible to blindly export value measures from one system without putting them in context of the other. If you compare different health systems, between Countries in the region, USA and UK, and two major post Soviet countries you can see that for health outcomes, it could be argued that the USA is not getting value for its money.

Total population
9.2 28.2 142.4 18.4 64.4 324.0
adult prevalence %
37.70 33.00 26.20 23.70 26.90 33.00
Life expectancy at birth
m/f (years)
75/80 74/80 65/77 67/76 79/83 77/82
Infant Mortality Rate
m/f (per 1,000 live births)
12/9 16/11 8/6 23/18 5/4 6/5
Hospital Bed Density
/1000 Population
1.1 2.1 9.7 7.2 2.9 2.9
/1000 Population
1.56 2.57 3.31 3.27 2.81 2.55
Total expenditure on health
as % of GDP
3.6 4.7 7.1 4.4 9.1 17.1

There may be a greater value placed on reducing obesity and its inherent co morbidities in some countries or reducing infant mortality as indicators of the health of populations in others.

The other two of the quadruple aims are about the patient and the staff. It’s easy to measure staff retention and the factors which positively encourage that such as education. Additionally, technical areas such as the number of clicks taken to order or number of alerts in the system can also be relatively easily measured, because many of these are time and money issues, saving 10 minutes here and 10 minutes there.

In all my time working with clients I have never yet met a nurse who has thanked me for the 10 minutes, whilst sitting with her feet up having a cup of tea. What happens is that the nurse repurposes that 10 minutes and puts it toward what is valuable to them; patient care, professional growth, improving other workflows. Doctors take their 10 minutes and spend more time talking with patients improving quality of care and patient safety, admin staff can do more than just register patients, lab staff and radiographers can do more than just correlate results and have more time to examine results. Consequently, the value to the staff is not time and money itself but what they do with it to improve patient care, spending more time with people who want to ask questions, be comforted, and be treated as humans.

If we really want to focus on value we need to recognize that the tangible measurements of time and money have intangible benefits for staff and patients, which may be harder to measure but are in no way less important. Even if an initiative does not save time or money overall but improves outcomes or reduces suffering it is no less valuable.

I believe we should start by measuring patient outcomes such as less pain, lower anxiety, more education, and improved patient and family happiness in a simple manner. The UAE is working to improve the happiness of all its citizens3, and is trying to measure how it has improved; all public and private organisations are tasked with improving the happiness of the population, and the overall happiness index measured and published. We, in the business of health care anywhere in the world, should take a lead from this, and have simple measures of patient happiness at every touchpoint, to measure the value of these intangible benefits at the point where they are most appreciated, by the patient.

  1. Institute of Healthcare Improvement
  2. New Risk, New Business Models, Turning Value-based Health care into a Real Business Model. NEJM Catalyst 24/10/2016 Thomas H Lee & Laura S. Kaiser