Relational Value: Bridging the Worldview Gap Between Patients and

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Relational Value: Bridging the Worldview Gap Between Patients and Health Systems John P. Zubialde, MD; James W. Mold, MD, MPH Since its inception, family medicine has understood the importance of a holistic approach to health care and the benefits stemming from integrating health care resources. This approach and its benefits have not, however, been fully appreciated by consumers, payers, and policy makers, especially in today’s dynamic marketplace. Articulating the benefits of an integrated approach is more likely to be effective if done in the language of the marketplace and in a framework that helps them understand the critical importance of relationships that are needed for integrating consumers’ needs with resources in systems. By using the concept of “value” recognized within the marketplace, this article creates a new framework for visualizing integration and relationships. It then embodies the benefits within a new term called relational value. With this concept and terminology, primary care physicians should be able to more effectively communicate to administrators and policy makers the added value of a holistic approach. Lastly, two ideas for creating relational value are discussed to help point the way to new health care delivery models. (Fam Med 2001;33(5):393-8.)

Value in Health Care Relationships Bringing patients and clinical resources together in a comprehensive, integrated fashion over time to improve health is the foundation of family medicine. This concept is predicated on the belief that such an approach provides benefits that are not realized in nonintegrated forms of care. 1-3 Articulating the benefits of this approach will be critical to the continued success of family practice in the health care marketplace. Additionally, these benefits must be addressed in terms familiar to both payers and the public and within a conceptual framework that makes their relevance explicit.

From the Department of Family and Preventive Medicine, University of Oklahoma.

Today, success in the health care marketplace is often defined using the concept of customer “value.”4-6 Understanding the meaning of value and how it is created is, therefore, critically important. This article uses the concept of value to demonstrate why relationship and integration matter and defines a new term, relational value, that more fully embodies the benefits of a primary care approach. Lastly, we propose two ideas for creating relational value that could serve as a foundation for future primary care delivery models. Defining Value in Health Care Quality Within the current management paradigm of payers and health systems, value is defined in terms of quality and cost (ie, value=quality/ cost). Quality is most typically defined as the ability to achieve spe-

cific quantifiable outcomes that are desirable to patients, health systems, and/or payers.7-9 More recently, the term service quality has also been used to describe those specific elements in the process of care that make patients’ experiences more positive.10 Examples include responsiveness of staff, reliability, comfort, accessibility, fewer hassles, etc. These conceptualizations of quality lead to an overly simplistic view of health care.11 This should not be surprising since managers of health systems have generally spent little time in the examination room or at the hospital bedside. Attempts to reorganize health care delivery systems have tended to focus almost entirely on the efficient and accurate diagnosis and treatment of disease and have used processes that are mechanical, quantifiable, and subject to principles of hard science,

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engineering, and quality management. The less quantifiable aspects of care, such as relationships, emotional and spiritual growth, encouragement and support, palliation, and being there through difficult times, are therefore left out of calculations of time, reimbursement, and the organization of personnel and resources. Many patients, if asked, might agree with the simpler view that focuses on efficiency and accurate diagnosis. However, these same patients are often disappointed when that is all they get, and they aren’t always sure why. Many family physicians also accepted this simpler perspective until we experienced the effects of a system that discounts relationships with patients and regards our services as interchangeable commodities to be bought and sold at the lowest price, often leading to discontinuity in patient care.12 A more robust definition of quality, therefore, requires the inclusion of an element that has been forgotten in the quest for efficiency. This element is the perceptual and cultural difference that naturally exists between the divergent belief systems of patients and providers and the worldviews that underlie them.13 Consumers rarely define quality in terms of the same quantifiable outcomes used by the health care industry. Instead, they are more likely to define it subjectively on scales that relate to individual perceptions of the benefits associated with health care resources and the fairness and responsiveness of the systems controlling those resources. 5,7,8,14,15 These perceptions are strongly tied to individual needs, desires, and beliefs about health and illness. They lead to complexities that are not captured in current valuations. Fortunately, studies addressing end-of-life care have clearly shown the importance of defining quality from a broader psychosocial and spiritual perspective.16,17 Similarly,

in the care of people with diabetes,13 we have learned that differing beliefs and attitudes toward this disease and its therapy can become obstacles to effective collaboration. In this case, outcomes valued by providers and payers are highly affected by patient behaviors and the individual beliefs and attitudes they hold.13 Even though we intuitively know this, it is uncommon for physicians to explore patient beliefs or their own beliefs when seeking to improve a patient’s health. Frankly, the powerful effects of worldviews have simply not been appreciated in today’s scientifically oriented medicine. Cost Cost is typically defined as the resources (usually quantified in a monetary denomination) that are required to produce the outcomes defining quality.6,15,18-20 The more specific the outcomes and knowledge of the resources required, the better the costs can be defined. Here again, health administrators, systems, and payers attempt to reduce subjectivity by limiting costs to those that are well-defined and stable. Just as with quality, however, individual patients have varied perceptions of the cost of health services.5,6,15,18 Costs of services and resources are likely to be thought of in terms of perceived liabilities and sacrifices pertaining to individual circumstances and needs. 5 Understandings of the direct monetary costs can also vary widely depending on the degree to which individuals are shielded from an awareness of cost because of insurance or other indirect payment mechanisms. 15 Thus, differences between individual perceptions created by the divergent perspectives and worldviews between consumers, providers, and payers can be quite large.

Defining the Gap The divergence between definitions and perceptions of quality and costs among the parties involved in health care relationships can result in substantial differences in valuation. Understanding the factors creating value differences and how to address them is critical. To clarify this concept, we introduce a term that we call the worldview gap. The gap exists where differing beliefs, understanding, and expectations separate the parties that come together when a health care relationship is created. It is exemplified by the sense of uncertainty you experience when working in a foreign culture. It is the place where effective bridges must be built if parties are to work together in a truly collaborative fashion (Figure 1). If not acknowledged, understood, and effectively bridged, this gap can cause conflicts, dissatisfaction, and suboptimal health care.21-25 Such conflict is exemplified today by the sociopolitical “war” against managed care.21,22 Managed care has successfully defined and framed value in health care from an analytical management model representing the primary worldview of payers and disease managementoriented health providers.15,26 However, to the average person, managed care simply represents the idea that there are resources that they may want or need, and someone can create barriers to their getting them. Some recognition exists that this conflict is not just due to a lack of information or a battle of wills but actually represents a fundamental conflict of worldview.15,22,23 However, little work has been done to better understand and explore innovative ways to bridge it. Most efforts have instead focused on strategies for providing traditional datadriven performance information to consumers (eg, Health Plan Employer Data and Information Set: HEDIS), hoping that this will highlight the benefits of managing care. While such information provides

Commentary what systems, payers, and those purchasing insurance products deem important, it may not satisfy individual patients who have differing expectations and understand things in fundamentally different ways.22,23,27-29 Effects of the Gap Since the gap exists because of differing ways of viewing health and health care resources, we can also anticipate that with rapidly expanding technologies and services overwhelming consumers’ abilities to understand their purpose, utility, and application, the gap will only continue to widen. The simple existence of a resource that might benefit a perceived health need may be enough to create a strong sense of desire for that product, whether or not providers and health systems define it as cost-effective or even appropriate. A good example of this is the recent public infatuation with electron beam computerized tomography to detect coronary artery disease.30 In locations where this test is being advertised, consumers are lining up to pay $600–$800 for it. Simultaneously, the American College of Cardiology and the American Heart Association state that evidence does not support its use as a screening tool in asymptomatic patients.31 The gap may also effectively separate beneficial resources from consumers so that the resources cannot be understood, valued, or accessed. This is exemplified by the failure to offer surgical procedures to elderly patients that might benefit them because the operative risk may adversely affect the surgeon’s “report card” that quantifies the surgeon’s value to the system. The cost of value misalignment is manifested every day through inefficient use of services, lack of satisfaction of patients with their health care systems, and less than optimal health outcomes.11,24,32,33 Medicine’s inability to bridge this gap represents a failure to acknowledge and deal with the important

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Figure 1 The Worldview Gap

effect of differing beliefs and worldviews. Additionally, the longer the gap is ignored, the wider it is likely to grow and the more serious its complications. As health care providers and health system managers, we can stay comfortably focused on a technological/analytical definition of health, or we can begin to acknowledge, understand, and address the worldviews, values, and desires of the human beings and communities wherein health resides. If we are to do this, value must not only be defined by quality and cost derived in an analytical fashion but also in terms of the ability to bridge the gap. This ability to bridge the gap results in an alignment we will define as relational value. Relational value objectifies the reasons for needing higher levels of relationship than currently exist in medicine and refocuses efforts on creating practice models that create common purpose, bring integration through more successful health care relationships, and build new areas of knowledge and understanding to those involved. Success in integrating the relationships between these various factors is relational value.

Creating Relational Value Finding ways to create relational value is, in our estimate, the single most important task for medicine in the next several decades and the natural niche for family medicine, given its longstanding emphasis on relationship and integrational process of care. It could also become the common thread uniting primary care disciplines. Service industries outside of medicine have already recognized its importance and are now creating ways to achieve it using new types of integration managers and leaders.34 We suggest that two ideas be used to guide these efforts. Idea 1: Goal-directed Care The current paradigm of clinical practice remains predominantly problem oriented. Problems in this context represent things that can be isolated and fixed in a mechanical fashion, much as a mechanic fixes problems with a vehicle. This mechanical process sorts problems into those that have scientific/ technological solutions and those that don’t. Straightforward problems with technological solutions get fixed via those means and be-

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come targets for benchmarking and critical pathways. Priority for problem solving is placed on availability of solutions rather than on a problem’s potential influence on meaningful endpoints like length or quality of life. More complex issues, such as overlapping chronic diseases, social and behavioral issues, and end-oflife care don’t fit well into this model. These issues require a high degree of common understanding to affect real value. Instead, they are often dissected in an attempt to simplify them, divided up among specialists and subspecialists, or simply left out of a therapeutic equation. We suggest changing the focus from problems to goals. Goals, unlike problems, land squarely in the middle of the gap, requiring ownership by all parties in a health care relationship (Figure 2). Problems are to goals as hurdles are to the finish line. Goals are individually important outcomes about which there is no need to ask “why?” For example, when a physician suggests that a patient lower his blood pressure to 135/85, the patient might reasonably ask “why?” to which the physician could answer “to lower your risk of developing congestive heart failure.” The patient might again ask “why?” The goals for this patient would be a meaningful (as determined by the patient) increase in life expectancy and a meaningful reduction in the risk of conditions that might adversely affect that individual’s quality of life. Thus, hypertension could be seen as an obstacle and blood pressure reduction as a strategy to help accomplish the goals. Potential costs and adverse effects of this strategy would be weighed

Figure 2 Focusing on Goals: Bridging the Gap

against the importance of the goal and the likelihood that the strategy would result in its achievement. A goal-directed health care model thus links parties together by creating common focus and purpose. This starts the process, tying consumer, providers, systems, and resources together in a collabora-

tive relationship.35-37 Through this relationship, alignment can be forged. While it may be impossible to fully merge the worldviews of patients and health providers, goals serve as the focal points at which melding occurs, creating relational value.

Figure 3 Narrowoing the Gap: Alignment Through Change

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Commentary Unlike current gatekeeper models, efficiency comes not by allocating resources via a managerial process but comes from focusing the most appropriate resources where they really count toward achieving goals that matter.38,39 Idea #2: Understanding and Facilitating Change A second conceptual change is necessary to maximize relational value. This requires the understanding that relationship building and goal achievement are an evolving process that involves dynamic change. While limited goals may be achieved through a problem-oriented approach, more complex or ambitious goals require behavioral change, growth, and realignment of understanding and priorities. Therefore, to complete the picture, we must add another component, specifically, consumers and health systems must enter into in a collaborative and longitudinal growth process. (Figure 3). Therapeutic models based on change theory, or the science of how people and organizations change, are becoming the foundation for dealing with such difficult health issues as AIDS prevention, alcohol and drug abuse, and smoking cessation. 40 Change theory recognizes that developing meaningful goals is only the beginning. Levels of personal awareness, values, worldviews, and circumstances then affect both the path to be chosen and the resources required. Without incorporation of change theory, important goals may become elusive and efforts to achieve them costly and ineffective. This approach within a goal-directed format was recently studied in a randomized controlled trial involving low-back pain patients. Through the development of clear goals and facilitative longitudinal relationships, patients achieved twofold greater improvement in functional status, less use of specialized testing, and twice the amount of behavioral change toward use of

exercise.41 Fortunately, literature in this area is growing.40,42-44 Systems and diffusion science are providing substantial insights.38,43-49 Relational leadership models are demonstrating how to set change in motion.45,46,50-52 These are exciting new arenas that will be of extreme importance to us if we are willing to look outside of our own medical worldview and embrace them. Conclusions This paper has acknowledged the importance of including the effects of worldview and relationships on how we estimate value in health care. Relational value, a new term that should be incorporated into value estimations, provides the framework for bridging the gap between providers, health systems, and consumers. The ability to maximize relational value when working with the complexities of real world problems will be critical to providing health care that we can all be proud of. As for the discipline of family medicine, the ability to create relational value must become what distinguishes us from all other disciplines. By incorporating new concepts of goal-directed care, change theory, and relational leadership to practice and research, we can build new tools and models that bridge the gap and create relational value. We hope that this discussion will stimulate dialogue on this important subject. Corresponding Author: Address correspondence to Dr Zubialde, University of Oklahoma Health Sciences Center, Department of Family and Preventive Medicine, 900 NE 10th Street, Oklahoma City OK 73104. 405-271-2569. Fax: 405-2714366. [email protected].

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