Straight Talk about the Value Proposition in Health Care

Higher education has a relative value problem.

The product of higher education is widely embraced in the United States: 20 million students attend our 3000 schools of higher learning. Per the Bureau of Labor Statistics, a college grad can expect to earn 1.7-2.7 times the lifetime income of a student who finished high school and entered the workforce. A college degree provides higher employment security: in 2012, the unemployment rate for college grads was 4.5% versus 8.3% for those with high school diplomas. Colleges play a key role in our local communities—for economic development, workforce development and as a major employer. And a recent Pew Research survey (February, 2014) found 9 of 10 with college degrees believe the investment has or will pay off.

Higher education does not have a value problem: its value proposition against the option of not getting a degree is solid.  But higher education has a relative value problem.

Since 1985, the price of higher education has increased 538% versus medical costs (+286%) and the consumer price index (+121%).  Stated differently, annual tuition increases have been 7.4%–more than healthcare (5.8%) housing (4.3%) and family income (3.8%). Last year, students and families paid $154 billion in tuition and fees to attend college: 60% borrowed $106 billion to help pay their bill. In the end, 38%  enrolled in four-year degree programs and 21%  in two-year degree programs will not graduate on time. One in seven with student loan debt will be delinquent on their debt, and student loan indebtedness, now at $1 trillion, will shortcut household discretionary spending that might otherwise be injected in our economy. And incomes for college grads have stagnated for the past 12 years.

The perplexing question facing higher education is this: does a college degree pay? And more precisely, what is <em>relative value</em> of each institution’s offering given alternatives? Consider…

• What’s the relative value of online degree programs versus traditional campus based?

• How important is a tenured faculty system in producing better student outcomes versus adjunct teachers with relevant industry experience?

• What’s the relative value of competency-based curricula compared to traditional liberal arts pedagogy?

• What’s the difference in private or public honors programs, or an Ivy League degree versus the local state school option?

• What’s the relative value of top tier collegiate sports versus an intense focus on classroom proficiency exclusively?

• And what’s the relative value difference between a degree costing $200,000 for four years versus the same degree for $40,000?

The market is forcing these questions about the relative value of higher education. Disrupters like Western Governors University and others are offering fresh options—a bachelor’s degree in 3.1 years from an accredited university for $19,000 total. And independent websites like Payscale.com, CollegeRiskReport.com, CollegeRealityCheck.com and others are forcing the issue via independent websites that quantify differences in tuition, student achievement on standardized tests, and job placement.

Relative value is a term rooted in investing: it compares the attractiveness of one investment over others in terms of risk, liquidity, and return. In healthcare circles, it’s most prominently used to set Medicare reimbursement rates for physicians using the complicated Resource-based Relative Value Scale, and more recently in the Affordable Care Act’s Comparative Effectiveness Research effort wherein treatments will be compared based on efficacy and effectiveness.

Healthcare in the U.S. does not have a value problem. Like higher education, it does not need to demonstrate that our system outperforms others of the world in availing caregivers the latest technologies and life-saving heroics<em>. We are quite proficient in declaring our value; we are quite challenged to assert and validate our relative value. </em>And that’s what our market is asking…

• What’s the value of health insurance? How do alternatives compare?

• Why do prices for routine procedures and tests vary so widely across communities and regions, and how can what’s paid be compared to alternatives when outcomes and underlying costs are unrelated?

• Why are there 1400 hospitals among the “Top 100”?

• Why does each insurance plan’s small print defy side-by-side comparison against others?

• Why do drugs with the same ingredients in the same amounts have different efficacy and different prices? And how do alternative remedies and over the counter options compare?

• Why do academic medical centers cost dramatically more than community hospitals for routine treatments with similar results? Or routine preventive health when delivered by nurses or physicians?

• How do end of life options compare versus expenditures and heroics that rob families and patients of resources and peace of mind?

• What differentiates between an “essentially equivalent” device that enters a market overnight and a similar that required years to get approval?

• Why does a nurse practitioner get paid half what a physician gets paid to diagnose a simple, uncomplicated medical problem? And what’s the difference in retail clinics operated by drugstores versus those sponsored by health systems?

• What’s the relative balance of a high performing system’s high tech, high touch investments in care?

• What are we getting for $9000 we spend on healthcare for every man, woman and child in the U.S. when outcomes of systems that spend significantly less rival ours?

And many others.

Granted, there are big differences between higher education and health care:

• Higher education is optional to most consumers; health care use is not optional, though health insurance is. Everyone’s a user of the health system. 

• Higher education uses a B2C operating model: colleges and universities target prospective students and their families. By contrast, health care operates in a B2B world. Consumers play a lesser role in deciding which drugs and devices are used and have nominal influence on prices and the quality of service delivery.

• Higher education is largely self-governed; health care is more heavily regulated at the state and federal levels.

But the challenges facing the two industries are directly comparable:

• The demand for “traditional approaches” is declining. From 2010 to 2012: enrollment at 25% of private 4-year college and universities declined 10% of more versus 20% for the period from 2006 to 2009. To replace traditional students, adult programs and non-degree classes have taken their places. In healthcare, demand is shifting from specialty care to intensified primary care, serving a wider range of populations with unique expectations and clinical problems. 

• Margins are shrinking in core businesses: “…nearly half of the nation’s colleges and universities are no longer generating enough tuition revenue to keep pace with inflation, highlighting the acceleration of a downward spiral that began as the recession ended” (Moody’s Investor Service)). Likewise, in many traditional settings– acute hospitals, home care, medical specialties and others—operating surpluses have disappeared replaced by ancillary services and new programs.

• Information technology is disrupting operating models: 45% of college students do online classwork today (Crux Research). From 2001 to 2011, colleges added more staff for non-classroom support than faculty (+57% increase in admin staffing versus a +37% increase in instructors per the US Department of Education). Ditto health care: electronic medical records with built-in clinical decision support tools for diagnosing and treating medical problems is replacing bedside manner, and e-visits, distance medicine, personalized therapeutics, mobile healthcare, applied analytics and predictive models are here to stay. Informediaries in both industries are powerful equalizers that fuel access to facts and figures about relative value.

• And price sensitivity is a big issue in each.

I have spent more than $450,000 educating my children in public and private colleges. Two have also completed graduate programs.<span>&nbsp; </span>It’s an investment in their futures. But I have frequently pondered the relative value of the investment: could I have spent less and gotten more, perhaps used the difference to fund a learning activity of a different sort altogether—perhaps a six month sabbatical to work with the underserved, or travel to unseen parts of the world to engage with different cultures. In the end, I rationalize the investment worthwhile, but the periodic dissonance can be perplexing.

The relative value of the health care industry, like higher education, is an unfolding story. The industry is attracting new competitors that are unconstrained by the traditional ways we deliver and finance care. They break rules set by incumbents. They don’t worship sacred cows. They’re nimble and focused: they see the relative value issue opportunistically.

The U.S. healthcare industry does not have a value problem; it has a relative value problem. Others see it, perhaps better than we do. It’s a discussion we need. It requires straight talk.