Value-Based Health Care Delivery: The Agenda for …...Principles of Value-Based Health Care...

This presentation draws heavily on Professor Porter’s research in health care delivery including Redefining Health Care (with Elizabeth Teisberg), What is Value in Health Care, NEJM, and The Strategy That Will Fix Health Care, HBR (with Thomas Lee).

A fuller bibliography is attached. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means — electronic, mechanical, photocopying, recording, or otherwise — without the permission of Michael

E. Porter. For further background and references on value-based health care, see the website of the Institute for Strategy and Competitiveness.

Value-Based Health Care Delivery:

The Agenda for Surgery

Professor Michael E. Porter

American College of Surgeons’ Clinical Congress

Boston Convention Center

Boston, MA

Wednesday, October 24, 2018

Copyright 2018 © Professor Michael E. Porter

Disclosure

2

Michael Porter

I have a relevant financial relationship with the following companies:

Company Role

Vanderbilt University Medical Center Advisor

Allscripts Advisor

AZTherapies Advisor, Investor

Ascent Biomedical Ventures Investor

Biopharma Credit Investments Investor

Advanced Aesthetic Tech. Investor

Merck & Co. Investor

Merrimack Pharmaceuticals Investor, Former Board Member

Molina Healthcare Investor

Royalty Pharma Investor

Thermo Fisher Scientific Investor


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The Health Care Problem Remains a Global IssueHealth Care Spending vs GDP and Income

1. Sweden changed reporting methodology and included long-term care spending in 2011, but not prior to 2011; thus HC spend for Sweden is indexed 1995-2010 and 2011-2016 with GDP growth 2010-11. Notes: All indexes based on local currencies; Income = Personal Disposable IncomeSource: WHO, EIU (May 2017), BCG analysis

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(1995=100)HC expenditure 2016:

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HC expenditure 2016:

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HC expenditure 2016:

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Index

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11.8% of GDP

Index1


10.9% of GDP

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(1995=100)

Index


9.2% of GDP

Personal Disposable Income Gross Domestic Product (GDP) Health Care Spending

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http://upload.wikimedia.org/wikipedia/commons/4/4c/Flag_of_Sweden.svg

//upload.wikimedia.org/wikipedia/commons/a/a4/Flag_of_the_United_States.svg


Issues Facing Surgeons Today

4

The • role of surgeons in future health care delivery

The • implication for surgeons of a cost-sensitive world

How to • measure quality and performance in surgery

Where surgery fits • in new reimbursement models

How to address administrative burdens • and burnout

Copyright 2018 © Professor Michael E. Porter5

Incremental “Solutions” Have Had Limited Impact

Evidence• -based medicine

Safety/eliminating errors•

Prior authorization•

Patients as paying customers•

Electronic medical records•

• “Lean” process improvements

Care coordinators•

Programs • to address high cost areas

(e.g. readmissions, post acute)

Mergers and consolidation•

IBM Watson•

Personalized medicine•

Restructuring health care delivery• is needed, not incremental improvements


Creating a Value-Based Health Care System

Today• ’s care delivery approaches reflect legacy organizational structures,

management practices, and payment models based on historical medical

science and delivery practices

There have been • significant advances medical science yet service

delivery practices have not evolved.

Health care has gotten lost in the • complexity of the system and the pursuit

of multiple goals including patient experience, safety, efficacy, access,

research and training, etc.

6

In order to transform the system, we need a • single, unifying goal

that aligns all interests


Solving the Health Care Problem

The • fundamental goal and purpose of health care is to improve value

for patients

Delivering high value health care is the • definition of success

Value is the only goal that can • unite the interests of all system

participants

Improving value is the • only real solution

The question is how to design a health care delivery system that •

substantially improves patient value

Value =Health outcomes that matter to patients

Costs of delivering these outcomes

7


Principles of Value-Based Health Care Delivery

Value =The set of outcomes that matter for the condition

The total costs of delivering these outcomes over the full care cycle

In • primary and preventive care, value is created in serving

segments of patients with similar primary and preventive

needs

The medical condition is the proper unit of • value creation

and value measurement in health care delivery

• Value cannot be understood at the level of a hospital, a

care site, a specialty, an intervention, a primary care practice

or a broad population

• Value is created in caring for a patient’s medical condition

(acute, chronic) over the full cycle of care


1. Re-organize care around patient conditions, into integrated

practice units (IPUs)

For primary and preventive care, IPUs serve − distinct patient

segments

Measure 2. outcomes and costs for every patient

Move to 3. value-based reimbursement models, and ultimately

bundled payments for conditions and primary care segments

Integrate multi4. -site care delivery systems

Expand or affiliate 5. across geography to reinforce excellence

Build an enabling6. information technology platform

9

Creating Value-Based Health Care Delivery The Strategic Agenda


Existing Model:

Organize by Specialty and Discrete Service

New Model:

Organize into Integrated Practice Units (IPUs) Around Conditions

Source: Porter, Michael E., Jain, Sachin, The University of Texas MD Anderson Cancer Center: Interdisciplinary Cancer Care. February 26, 2013.

Outpatient

Oncologist

Surgical

Oncologist Speech &

Swallow

Dentist

Primary Care

Physician

Radiation

Oncologist

RadiologistPathologist

Re-organize Care Around Patient Medical ConditionsHead & Neck Cancer Care at MD Anderson

10


Integrating Over The Cycle of Care Acute Hip and Knee-Osteoarthritis

• Operating room

• Recovery room

• Orthopedic floor at hospital or

specialty surgery center

Specialty office•

Pre• -op evaluation center

• Specialty office

• Imaging facility

SURGICAL

Immediate return to OR for

manipulation, if necessary

MEDICAL

Monitor coagulation•

LIVING

Provide daily living support •

(showering, dressing)

Track risk indicators (fever, •

swelling, other)

PHYSICAL THERAPY

Daily or twice daily PT sessions•

ANESTHESIA

Administer anesthesia (general, •

epidural, or regional)

SURGICAL PROCEDURE

Determine approach (e.g., •

minimally invasive)

Insert device•

Cement joint•

PAIN MANAGEMENT

Prescribe preemptive •

multimodal pain meds

Meaning of diagnosis•

Prognosis (short• - and long-

term outcomes)

Drawbacks and benefits of •

surgery

IMAGING

Perform and evaluate MRI and •

x-ray

-Assess cartilage loss

-Assess bone alterations

CLINICAL EVALUATION

Review history and imaging•

Perform physical exam•

Recommend treatment plan •

(surgery or other options)

Nursing facility•

Rehab facility•

Physical therapy clinic•

Home•

MONITOR

• Consult regularly with patient

MANAGE

• Prescribe prophylactic

antibiotics when needed

• Set long-term exercise plan

• Revise joint, if necessary

Specialty office•

Primary care office•

Health club•

• Expectations for recovery

• Importance of rehab

• Post-surgery risk factorsINFORMING AND ENGAGING

MEASURING

ACCESSING

Importance of exercise, •

maintaining healthy weight

Joint• -specific symptoms and

function (e.g., WOMAC scale)

Overall health (e.g., SF• -12

scale)

• Baseline health status

• Fitness for surgery (e.g., ASA

score)

Blood loss•

Operative time•

Complications•

• Infections

• Joint-specific symptoms and

function

• Inpatient length of stay

• Ability to return to normal

activities

Joint• -specific symptoms and function

Weight gain or loss•

Missed work•

Overall health•

MONITOR

Conduct PCP exam•

Refer to specialists, if •

necessary

PREVENT

Prescribe anti• -inflammatory

medicines

Recommend exercise regimen•

Set weight loss targets•

Importance of exercise, weight •

reduction, proper nutrition

Loss of cartilage•

Change in • subchondral bone

Joint• -specific symptoms and

function

Overall health•

OVERALL PREP

Conduct home assessment•

Monitor weight loss•

SURGICAL PREP

Perform cardiology, pulmonary •

evaluations

Run blood labs•

Conduct pre• -op physical exam

• Setting expectations

• Importance of nutrition, weight

loss, vaccinations

• Home preparation

Importance of rehab adherence•

Longitudinal care plan•

Orthopedic Surgeon

PCP office•

Health club•

Physical therapy clinic•

DIAGNOSING PREPARING INTERVENINGMONITORING/

PREVENTING

RECOVERING/

REHABBING

MONITORING/

MANAGING

CARE DELIVERY


The Playbook for Integrated Practice Units (IPUs)Organized around a 1. medical condition, or group of

closely related conditions.

Defined patient segments for primary care−

Care is delivered by a 2. dedicated, multidisciplinary team

devoting a significant portion of their time to the condition

In− -house staff and affiliated staff with strong working relationships

3. Co-located in dedicated facilities. A hub and spoke structure connecting

multiple or affiliated sites, incorporating telemedicine where appropriate

Takes responsibility for the4. full cycle of care

5. Patient education, engagement, adherence, follow-up, and prevention

are integrated into the care process

The unit has a clear 6. clinical leader, a common scheduling and intake

process, and unified financial structure (single P + L)

7. A physician team captain, clinical care manager or both

oversees each patient’s care

The8. IPU routinely measures outcomes, costs, care processes,

and patient experience using a common platform

The team 9. accepts joint accountability for outcomes and costs

The team 10. regularly meets formally and informally to discuss individual

patient care plans, process improvements, and how to improve results12

10.


Volume Matters for IPUs and Value• More patients with the same condition enables higher value

Better Results,

Adjusted for RiskRapidly Accumulating

Experience

Rising Process

Efficiency

Better Information/

Clinical Data

More Tailored Facilities

Rising

Capacity for

Sub-Specialization

More Fully

Dedicated Teams

Faster Innovation

Greater Patient

Volume in a

Medical

Condition

Improving

Reputation

Costs of IT, Measure-

ment, and Process

Improvement Spread

over More Patients

Wider Capabilities in

the Care Cycle,

Including Patient

Engagement

The Virtuous Circle of Value

Greater Leverage in

Purchasing

Better utilization of

capacity


Focuses on • low-income older adults living in under-served urban

communities

Four severity tiers–

Multidisciplinary team • covering the full care cycle: physicians, PAs, NPs,

RNs, medical assistants, scribes, care managers, social workers, clinical

informatics specialists, and others

Co• -located in dedicated facilities. 40 sites across the Midwest

Explicit processes to • engage patients and reduce obstacles

to accessing care such as free rides/home-visits, in-house pharmacy

and selected events for community residents

Selected in• -house specialty services such as behavioral health and

podiatry. Close relationships with outside specialists selected based on

outcomes, cost and ability to work with integrated model

Meet daily and weekly • to discuss patient care plans and process

improvement

Measure and accountable • for outcomes, cost, and patient experience

Single full• -risk value-based payment covering overall care

Includes specialty and post– -acute care

Value-Based Primary CareOak Street Health


Patient Experience/

Engagement/ Adherence

E.g., PSA,

Gleason score,

surgical margin

Protocols/Guidelines

Patient Initial

Conditions,

Risk Factors

Processes Indicators

Structure

E.g., Staff

certification,

facilities standards

Measure Outcomes for Every PatientThe Quality Measurement Landscape

15

Outcomes


Survival

Degree of health/recovery

Time to recovery and return to normal activities

Sustainability of health/recovery and nature of recurrences

Disutility of the care or treatment process (e.g., diagnostic errors and ineffective care, treatment-related discomfort, complications, or adverse effects, treatment

errors and their consequences in terms of additional treatment)

Long-term consequences of therapy (e.g., care-induced illnesses)

16

The Outcome Measures Hierarchy

Tier

1

Tier

2

Tier

3

Health Status

Achieved

or Retained

Process of

Recovery

Sustainability

of Health

Source: NEJM Dec 2010

Achieved clinical status•

Achieved functional status•

Care• -related pain/discomfort

Complications•

Re• -intervention/readmission

Long• -term clinical status

Long• -term functional status

• Time to diagnosis and treatment

• Time to return home

• Time to return to normal activities


Source: ICHOM

17

9.2%

17.4%

95%

43.3%

75.5%

94%

Incontinence after one year

Severe erectile dysfunction after one year

5 year disease specific survival

Average hospital Best hospital

Measuring Multiple Outcomes Prostate Cancer Care in Germany

Source: ICHOM

Source: ICHOM


Source: ICHOM

18

9.2%

17.4%

95%

43.3%

75.5%

94%

Incontinence after one year

Severe erectile dysfunction after one year

5 year disease specific survival

Average hospital Best hospital

Measuring Multiple Outcomes Prostate Cancer Care in Germany

Source: ICHOM

Source: ICHOM


Localized Prostate 1.

Cancer *

Lower Back Pain 2. *

Coronary Artery 3.

Disease *

Cataracts 4. *

Standard Sets

Complete

(2013)

Breast Cancer*13.

Dementia14.

Frail Elderly15.

Heart Failure16.

Pregnancy and 17.

Childbirth

Colorectal Cancer*18.

Overactive Bladder19.

Craniofacial 20.

Microsomia

Inflammatory Bowel 21.

Disease

Standard Sets

Complete

(2015-16)

Parkinson5. ’s Disease*

Cleft Lip and Palate*6.

Stroke 7. *

Hip and Knee 8.

Osteoarthritis*

Macular Degeneration*9.

Lung Cancer*10.

Depression and 11.

Anxiety*

Advanced Prostate 12.

Cancer *

Standard Sets

Complete

(2014)

Chronic Kidney 22.

Disease*

Congenital Upper 23.

Limb Malformations

Pediatric Facial Palsy24.

Inflammatory 25.

Arthritis

Hypertension26.

Standard Sets

Complete (2017-18)

Standardizing Minimum Outcome SetsICHOM Standard Sets

* Published Thus Far in

Peer-Reviewed

Journals (14)

19

27. Oral Health

28. Diabetes

29. Atrial Fibrillation

30. Overall Adult Health

31. Pediatric Health

32. Hand and Wrist

33. Neonates

34. Head and Neck Cancer

35. Congenital Heart

Disease

36. Mental Health in Children

and Young People

Committed/

In Process


Measure Cost for Every Patient Principles

Cost is the • actual expense of patient care, not the sum of

charges billed or collected

Properly • measuring the cost of care requires different cost

accounting methods than prevailing approaches such as

departmental, charge-based, or RVU-based costing

Cost should be measured for • each patient over the full cycle

of care for the condition, or by primary care segment

Cost • is driven by the use of all the resources involved in a

patient’s care (personnel, facilities, supplies,

and support services)

– Time and actual costs, not arbitrary allocations

Understanding costs requires • mapping the care processSource: Kaplan, Robert and Michael E. Porter, “The Big Idea: How to Solve the Cost Crisis in

Health Care”, Harvard Business Review, September 1. 2011


Mapping Resource UtilizationMD Anderson Cancer Center – New Patient Visit

Registration and Verification

Receptionist, Patient Access

Specialist, Interpreter

Intake

Nurse,

Receptionist

Clinician Visit

MD, mid-level provider, medical

assistant, patient service

coordinator, RN

Plan of Care

Discussion

RN/LVN, MD, mid-

level provider, patient

service coordinator

Plan of Care

Scheduling

Patient Service

Coordinator

Decision Point

Time (minutes)

Source: HBS, MD Anderson Cancer Center


Major Cost Reduction Opportunities in Health Care

Utilize • physicians and skilled staff at the top of their licenses

Eliminate • low- or non-value added services or tests

Reduce • process variation that increases complexity and raises cost

Reduce cycle times• across the care cycle

Invest in additional services or higher costs inputs that will • lower overall

care cycle cost

Move uncomplicated services • out of highly-resourced facilities

Reduce • service duplication and volume fragmentation across sites

Rationalize redundant • administrative and scheduling units

Increase • cost awareness in clinical teams

Decrease cost of • claims management and billing processes

Our work reveals typical • cost reduction opportunities of 30+%

Many cost improvements also • improve outcomes


Accountable for costs and outcomes, •

patient by patient, and condition by condition

• A single risk-adjusted payment for the overall care for a life

Emerging Value-Based Payment Models

Capitation (Population-Based) Bundled Payment

Responsible for • all needed care in the covered population

Accountable for • population level quality metrics

At risk for the difference between the •sum of payments for the population and overall spending

Providers take − disease incidence risk, not just execution/outlier risk

Accountable• for overall cost and population level quality measures

• A single risk adjusted payment for the overall care for a condition

− Not for a specialty, procedure, or short episode

Covers the • full set of services needed over an acute care cycle, or a defined time period for chronic care or primary care

• Contingent on condition-specificoutcomes

− Including responsibility for avoidable complications

At risk for the difference between the •

bundled price and the actual cost of all included services

Limits of responsibility− for unrelated care and outliers

23


Walmart Centers of Excellence Programs

Conditions:Cardiac•

Cancer•

Joint replacement•

• Spine• Transplant• Weight loss

Partnerships:

Cleveland Clinic (OH)

Geisinger (PA)

Kaiser Permanente (CA)

Johns Hopkins (MD)

Mayo Clinic (MN)

Memorial Hermann (TX)

Northeast Baptist (TX)

Virginia Mason (WA)

Emory (GA)

Source: Compiled from news.Walmart.com and through publically available news and press releases . 24


Defining the 1. overall scope of services for each site, and for the

facility/system as a whole, where it can deliver high value

− Affiliate when this creates value

Concentrate2. volume of patients by condition in fewer locations to support

IPUs and improve outcomes and efficiency

Perform the 3. right services in the right locations based on acuity level,

resource fit, and the benefits of patient convenience for repetitive services

E.g., move – less complex surgeries out of tertiary hospitals to smaller facilities and

outpatient surgery centers

Integrate the care cycle 4. across sites via an IPU structure

Common– scheduling

Digital services – and telemedicine can help tie together the care cycle

25

Four Levels of Provider System Integration


Delivering the Right Care at the Right LocationRothman Institute, Philadelphia

Lowest Complexity

LowMedium

Highest Complexity

Facility Capability

Price of Total Hip

Replacement:

~$12,000 USD

Price of Total

Hip

Replacement

~$45,000 USD

Patient Risk Factors: Age, Weight, Expected Activity, General Health, and Bone Quality

Ambulatory Surgery Center

Rothman Orthopaedic

Specialty Hospital

Bryn Mawr

Community Hospital

Jefferson University

Academic Medical Center


Build an Enabling IT PlatformAttributes of a Value-Based IT Platform

Combines 1. all types of data for each patient across the full care cycle (notes, lab

tests, genomics, imaging, costs) using standard definitions and terminology

Tools to capture, store, and extract 2. structured data and eliminate free text

Data is captured in the3. clinical and administrative workflow

Data is stored and easily extractable from a common warehouse. Capability to 4.

aggregate, extract, run analytics and display data by condition and over

time

5. Full interoperability allowing data sharing within and across networks, EMR

platforms, referring clinicians, and health plans

Platform is structured to enable the capture and aggregation of 6. outcomes,

costing parameters, and bundled payment eligibility/billing

Leverages 7. mobile technology for scheduling, PROMs collection, secure patient

communication and monitoring, virtual visits, access to clinical notes, and patient

education


How Can Surgeons Create Value?

Think 1. beyond the operating room

Move away from − surgical silos and partner with caregivers in preventative

care, perioperative care, rehabilitation, short-term follow up, surveillance

Institute 2. universal outcome measurement and public reporting to drive

improvement and demonstrate high value care

Utilize 3. time-driven activity-based costing methodology covering the full

cycle of care to demonstrate overall impact on efficiency and value

Actively engage in 4. bundled payments with employers, government

payers and private payers advocate for broader implementation

5. Reorganize care within a region to optimize resources

Aggregate volume by− condition in fewer sites

E.g.− lower acuity surgery in community hospital settings, higher

acuity/complexity surgery in tertiary care hospitals


29

Shifting to a Value-Based Mindset

Technician Condition Expert

Solo ActorHold a Key Role in the

IPU Team

Focus on SafetyInfluence Multiple

Patient Outcomes

Maintain Volume Across

Many Procedures

Become Expert in a

Few Conditions

Control Cost of a

Specific Procedure

Reduce Cost Over the

Complete Care Cycle

Drive Volume of

Services

Get Paid for High-Value

Care

Commodity Player Deliver Distinctive Value


Expanding the Role of Surgeons in the Care CycleThinking Beyond the Operating Room

Medical

Management

Preoperative

Care

Surgical

Intervention

Postoperative

CareRehabilitation Surveillance

Partner with •

medical

specialists to

manage

complex cases

and the ongoing

evaluation of

need for

surgery

Develop • non-

surgical

options with

other providers

• Collaborate with

primary care,

anesthesiologist

and applicable

specialized to

prepare patient

for successful

surgery

• Be accessible

to primary care

team for pre-

operative care

questions

Optimize the •

surgical

process

• Co-develop

best practices

with post-

operative teams

• Ensure

seamless

transition to

post op care

Shift post• -acute

care to

appropriate

settings (e.g.

home, rehab,

etc.)

Extended •

clinic hours

and after-hours

hotline

Educate• home

health team and

PT on best

practices

Ongoing •

monitoring of

patients for

recurrence

Measure longer •

term outcome

measurement

Prevention &

Detection

Work with •

primary care to

prevent

progression of

disease

Advise primary •

care on

accurate

diagnoses and

timely referral


Value-Based Care Models are Already Taking Off in Surgery

• Multiple value-based health care models emerging, such as in trauma, bariatric,

and cancer care

• Well-established IPU models exists within transplantation

− Mandated outcome reporting by the National Organ Transplantation Act (NOTA)

− Multidisciplinary care model became the standard of care

− Early bundled payment for kidney transplant (UCLA & Kaiser)

− Rapid dissemination of best practices and scientific breakthroughs


40

50

60

70

80

90

100

0 200 400 600 800 1000

Source: Scientific Registry of Transplant Recipients, http://www.srtr.org

Adult Kidney Transplant Outcomes1987 - 1989

32

Percent

1-year

Graft

Survival

Number of Transplants 1987 – 1989 (Three Year Period)

Number of centers: 219

Number of transplants: 19,588

1 Year Graft Survival: 79.6%

16 Greater than expected graft survival (7%)

20 Worse than expected graft survival (10%)


40

50

60

70

80

90

100

0 200 400 600 800 1000

94.7%

Number of programs included: 209

Number of transplants: 38,370

1 Year Graft Survival:

4 Greater than expected graft survival (1.9%)

5 Worse than expected graft survival (2.4%)

Percent

1-year

Graft

Survival

Number of Transplants 2011 – 2013 (Three Year Period)

Adult Kidney Transplant Outcomes2011 - 2013

33


The Health Care Transformation is Well Underway

We • know the path forward

Value for patients • is the True North

Value based thinking • is restructuring care organization, outcome

measurement, health system strategy, and payment models across

multiple countries

Standardized outcome measurement • and new costing practices are

beginning to accelerate value improvement

Employers• , suppliers, and insurers can be the next accelerators

Government policy • is beginning to reinforce value improvement

We are anxious to • work with all of you in accelerating this

transformation34


Selected References on Value-Based Health Care

Porter, M.E., Teisberg, E. (• 2006). Redefining Health Care: Creating Value-Based Competition on Results. Harvard Business

Publishing.

Porter, M.E., Teisberg, E.O. (• 2007). How Physicians Can Change the Future of Health Care. JAMA;297:1103‐1111.

Porter, M.E. (• 2008). Value‐Based Health Care Delivery. Annals of Surgery; 248: 503‐509.

Porter, M.E. (• 2010). What Is Value in Health Care? New England Journal of Medicine.

Kaplan, R.S and Porter, M.E. (• 2011). How to Solve the Cost Crisis in Health Care. Harvard Business Review. September 2011.

Porter, M.E., Pabo, E.A., Lee, T.H. (• 2013). Redesigning Primary Care: A Strategic Vision To Improve Value By Organizing Around

Patients’ Needs. Health Affairs; 32: 516‐525.

Porter• , M.E. and Lee, T.H. (2013). The Strategy that Will Fix Health Care. Harvard Business Review. October 2013.

Porter, M.E. and Lee, T.H (• 2015). Why Strategy Matters Now. New England Journal of Medicine.

Carberry K., Landman Z., Xie M., Feeley T. (• 2015) Incorporating Longitudinal Pediatric Patient-Centered Outcome Measurement into

the Clinical Workflow using a Commercial Electronic Health Record: a Step toward Increasing Value for the Patient. Journal of

American Medical Informatics Association.

Ying A.,• Feeley T., Porter M. (2016) Value-based Health Care: Implications for Thyroid Cancer. International Journal of Endocrine

Oncology

Porter M.E., Larsson S., Lee, T.H. (• 2016). Standardizing Patient Outcomes Measurement. New England Journal of Medicine

Porter M.E. and Kaplan R.S. (• 2016) How to Pay for Health Care. Harvard Business Review. July 2016

Thaker N.G., Ali T.N., Porter M.E, Feeley T.W., Kaplan R.S., Frank S.J. Communicating Value in Healthcare using Radar Charts:• A

Case Study of Prostate Cancer. Journal of Oncology Practice. September 2016.

Witkowski M., Hernandez A., Lee T.H., Chandra A., Feeley T.W., Kaplan R.S. and Porter, M. E. The State of Bundled Payments, •

Working Paper. Unpublished. May 2017.

Websites Including Videos •

http://www.isc.hbs.edu/–

https://www.ichom.org/–

Case studies and curriculum guide available at: – http://www.isc.hbs.edu/resources/courses/health-care-courses/Pages/health-care-

curriculum.aspx

35

http://www.isc.hbs.edu/

https://www.ichom.org/

http://www.isc.hbs.edu/resources/courses/health-care-courses/Pages/health-care-curriculum.aspx

@[email protected] @meporter.hbs

www.isc.hbs.edu

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