Pyramid of Value It Has to Be About the Patient Robert Ripley MD Dec 18 2017 An important game changing article that puts Value in a new light is in the NEJM Dec 21, 2017 issue by Green and Loscalzo. The title is "Putting the Patient Back Together - Social Medicine, Network Medicine, and the Limits of Reductionism". Many widely known and emergent tools are explained that can bear on the current understanding of Value in the healthcare context. Most importantly this article shows how holistic patient centered approaches are not only cool, but doable and can be effective in achieving a broad range of goals on behalf of patients and populations. Value has many forms, created by health care activity but measured and understood by a community of providers and payors The understanding of care activity requires a framework for provider's multilevel assessment of populations, and this understanding is best when it is patient centered. In short, value, when used as a tool for care transformation, must come from a collective that benefits from a productive interaction of population and patient centering. Population value assessment requires risk stratification methods that allow population metrics to scale down through multiple dimensions. Starting from large populations for standards of care and global costs, to a collective of local providers and the smaller populations attributed to the collective, and finally to the individual provider and the wise decisions made for the patient, this multilevel framework can function to give context to wise clinical cost effective decisions. The Pyramid of Value provides such a framework. As complex as health care is, the collective when functioning so that the parts are transparent to each member of the collective and to the whole, will have new holistic functionality that accounts for all factors that affect care decisions. Holism gives meaning to collectives; the transparency that is the first principle of holistic care depends on standardization of the semantics or terms used in transactions, the translation across boundaries of specialized terms of members of the collective; these when coordinated will drive collaboration within the collective which is essential to achieving value. The Pyramid of Value, when used as a framework that supports cost reduction, starts at the pyramid's apex, and when patient centered, begins as transactions. The next level of the pyramid, are the alternative payment model programs that use financial benchmarks applied to small provider groups. These transactions of patient centered care then scale up to populations of a small size, managed by a part of the collective. The base level of the pyramid is for care transformation, where transactions are assembled into populations for the purpose of achieving the objective of patient centered value based purchasing for cost reduction. The pyramid can be a framework for channeling information in a coordinated way across scales of populations, yet can ultimately be patient centered. An important issue is to clearly delimit information that is population centered from information that is patient specific. It may seem clear to many observers, particularly those of the collective that want to provide value, that as metrics population averages are applied with the intent of modifying provider behaviors. However the activity at the patient level, where the question is asked of how to provide value, averages are a poor tool to inform granular patient wise decisions. The difference of population centered information applied to audit care activities, and patient centered information informing care decisions for most probable future outcomes, is vast, yet unclear. This issue of population centering versus patient centering warrants further discussion and may show a way to move past retrospective audits to support decisions and cost reductions that are more effective. The apex of the Value pyramid need not be only transactional. If functionality to achieve cost reduction is holistic, why not make the apex of the pyramid more than only transactional, but holistic. Thus the lower levels of the pyramid can be renamed to be more holistic as well. For example, alternative payment models, which mean simply cost and quality benchmarks applied to attributed populations of a small size, can become more general community based population metrics. This may include demographic, psychosocial, risk stratified groups, all of which are important to know for clinical reasons. Yet there is not a direct relation of these types of metrics that are under the control of wise decision makers, what is known as quarterbacks. The lowest level of the pyramid, care transformation, can be segmented into the features that are supportive of care transformation, but are not directly measured for impact on costs. This for example may include metrics that do not currently exist that measure coordination and collaboration of the collectives. The new focus on readmission rates and transitional care models are in reality surrogates for collaboration and transitions among members of the collectives. Few would argue that the greatest opportunity for cost reductions is with managing care transitions of all kinds. Holism is the holy grail of patient centered care based on understanding of all factors that affect health and disease. Knowing all the factors is a tall task, but with holism there is no limit to what is included in the mix of patient centered information. If there is no objective in assembling the information, other than knowing the patient, outcomes of this knowledge can be put to good use as needed. At the time, wise decisions are called for, providers of the collective look to the most desired outcome, and assess the probability of this outcome using their knowledge of the patient, opinions of respected peers, population guidelines, and their judgement mixes all this together. What operates here is what Greene and Loscalzo mean by a hierarchy of context, an organized way of matching patient centered and populations centered factors. More is included in their conception of holism. Scale-free networks, a theory from criminal justice, show how highly connected practices or individuals in a collective hold the most influence in care redesign; the age of data science of massive datasets is here, and they caution against using genomic and other omic knowledge as relevant for wise decisions. More importantly they maintain local knowledge, not necessarily statistically significant, is important for patient centered care. Local modular knowledge is a hallmark of artificial intelligence, and will give holism a boost. The question is always asked, "As a provider how do I provide Value?", the answer may be in holism, structured in a Pyramid of Value.