Gupta Reshma, Moriates Christopher
R. Gupta is a VA/UCLA Robert Wood Johnson Clinical Scholar, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, Los Angeles, California, director, outreach and evaluation and director, Teaching Value in Healthcare Learning Network, Costs of Care, Boston, Massachusetts.C. Moriates is assistant dean for healthcare value and associate professor of internal medicine, Dell Medical School at The University of Texas at Austin, and director of implementation, Costs of Care, Boston, Massachusetts.
Acad Med. 2017 May;92(5):598-601. doi: 10.1097/ACM.0000000000001485.
As health system leaders strategize the best ways to encourage the transition toward value-based health care, the underlying culture-defined as a system of shared assumptions, values, beliefs, and norms existing within an environment-continues to shape clinician practice patterns. The current prevailing medical culture contributes to overtesting, overtreatment, and health care waste. Choosing Wisely lists, appropriateness criteria, and guidelines codify best practices, but academic medicine as a whole must recognize that faculty and trainees are all largely still operating within the same cultural climate. Addressing this culture, on both local and national levels, is imperative for engaging clinicians in reforms and creating sustained changes that will deliver on the promise of better health care value. This Perspective outlines four steps for health system leaders to understand, cultivate, and maintain cultural changes toward value-based care: (1) Build the will for change through engaging frontline providers and communicating patient-centered motivations for health care value; (2) create necessary infrastructure to support value improvement efforts; (3) expose physicians to value-based payment structures; and (4) demonstrate leadership commitment and visibility to shared goals. The authors support their recommendations with concrete examples from emerging models and leaders across the country.
在卫生系统领导者谋划鼓励向基于价值的医疗保健转型的最佳方式时，作为一种在环境中存在的共享假设、价值观、信念和规范体系的潜在文化，仍在继续塑造临床医生的执业模式。当前盛行的医学文化导致了过度检查、过度治疗和医疗保健浪费。“明智选择”清单、适宜性标准和指南将最佳实践编纂成法典，但整个学术医学领域必须认识到，教师和学员在很大程度上仍在相同的文化氛围中运作。在地方和国家层面解决这种文化问题，对于促使临床医生参与改革并创造可持续的变革以实现更好的医疗保健价值的承诺而言至关重要。本观点文章概述了卫生系统领导者理解、培育和维持向基于价值的医疗保健的文化变革的四个步骤：（1）通过让一线医疗服务提供者参与并传达以患者为中心的医疗保健价值动机来建立变革意愿；（2）创建必要的基础设施以支持价值提升努力；（3）让医生接触基于价值的支付结构；（4）展示对共同目标的领导承诺和可见度。作者用来自全国各地新兴模式和领导者的具体例子来支持他们的建议。
