Repositioning the Medical Professional for Value-Based Care and the Principles of Bioethics

Medicine cannot be just a source of wealth, gain, profit. It is, above all, a profession, an activity. It is not a shelf product, to be “consumed” by fashion or opportunism.

Fair and deserved remuneration must be the consequence, the effect and never the cause, the objective of clinical decision-making.

Joint clinical decision-making, shared between doctor and patient / family, must be based on scientific evidence of indication (eligibility criteria) and contraindication (exclusion criteria) but, above all, must be based on principles ethical: autonomy, non-maleficence, beneficence, justice and equity.

Most cases will fall into the extremes of eligibility or exclusion. But there are many cases with more than one evidence-based therapeutic indication, more than one possible approach. In these cases, collegiate decision making is mandatory, with the participation of peers, superiors and, mainly, the patient and the family.

This structure for clinical decision-making causes the need for redesign in clinical decision-making microsystems, according to the profile. Ambulatory and Urgency and Emergency Unit are good examples. The presence of a medical coordinator of the service or a chief of staff for shared, collegiate decision making appears here as one of the suggested models. And an ambulatory for the pre-hospital phase also needs a multidisciplinary structure for accurate and relevant clinical decision-making.

In addition, it is necessary to standardize a predetermined flow to trigger higher levels when there is a need to make a decision that involves financial or legal impact, which fall outside the purview of the coordinator.

All these initiatives foresee a disruption in the current models, as it presupposes a barrier to the autonomy of the doctor, the prerogative of his profession and determined by a code of medical ethics. However, this collegiate decision-making model works exactly in the opposite direction, that of professional protection, of civil liability. And it must be contested, arguably, if it violates the principles of bioethics.

Structured model, clinical decision-making based on scientific evidence and principles of bioethics, we have established the context for the construction of the value-based result.

The clinical outcome should then be measured not only by the aspect of technical success, but mainly by its impact on the patient’s biopsychosocial condition (quality of life in relation to expectations), on the personal satisfaction of the professionals involved and on the economic-financial dimension for the institution and the health system.

Care lines need to be structured based on the result of value to the patient, people, institution, and system and not just on technical quality and expected results from microsystems. This measure is important, but it is not enough. Processes need to be effective and efficient. But the patient needs clinical effectiveness. Care models within the same line of care need to be customized, patient to patient and aligned with their individual needs and expectations.

Thus, the expected results of the lines will never have absolute values for certain parameters, but an interval within which it is possible to observe an acceptable variability, as long as without damage.

It will take several cycles of control and improvement of results to find the ideal flow for each line in terms of the result of value.

Value here is defined as:

CLINICAL OUTCOME * RELEVANCE

VALUE =              ­­­­­­­­­­­­­­­­­_____________________________

COST

After this homogenization of conduct, standardization of procedures and inputs and a clear definition of the expected result, we can say that this care line is ready to generate value through the timely construction of individualized and coordinated therapeutic plans and projects, with the participation of the coproduction patient, respecting established standards and identified variability. The physician’s role in the construction of these therapeutic plans and projects is essential. Nothing will happen without medical participation.

The care lines of each institution must be defined according to the impact, that is, based on volume, risk, or cost, as recommended by any quality and patient safety program. But, now looking for the optimal result for everyone involved: patient, people, institution, and system. Once again, the role of the doctor here is fundamental, as we cannot build lines without medical teams.

Clinical managers now need to monitor these lines through specific markers (controls). And the result of value must be evidenced through a system capable of measuring value for each involved party: patient, people, institution, and system.

Although the outcome is a broad terminology, we can define specific intervals according to each monitored line, such as, for example, 30 days for clinical and surgical hospitalizations. In the meantime, complications, unplanned emergency visits, readmissions, reinterventions, or recurrences will be monitored. Post-discharge monitoring can show a great gain in value if the monitoring is extended for at least 12 months. It is unnecessary to emphasize the importance of the doctor in this construction since everything depends on evidence-based medicine.

The strategy for measuring value results presupposes effective action outside the walls, that is, before hospitalization and after discharge. This requires the implementation of an outpatient system also for graduates and chronic monitoring. Another impossible design without the doctor’s participation.

In conclusion, “Value-Based Health Care”, the much-vaunted Value-Based Health Care (VBHC) depends primarily on a medical staff fully inserted in a strong Bioethics structure, which guarantees free clinical decision making and without conflicts of personal interest .

Medicine is no longer a priesthood. But, for sure, it cannot be just a “business”.

The Psychologically Safe Environment and Professional Silence
Value-based Health Care

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