Intensive Seminar

From January 6-10, 2014, Professor Porter, together with other faculty, will teach the seventh annual one-week, full-time Value-Based Health Care Delivery Intensive Seminar. This non-credit, graduate-level program will be held at Harvard Business School and is open by application to Harvard MBA and MD students; others at Harvard pursuing health care-related courses of study; medical residents; junior physicians and clinicians at Boston area providers; and interested residents and clinicians from outside of Boston. The seminar utilizes case studies, guest protagonists, concept lectures, and other materials to present the fundamental principles of value-based health care delivery and examine organizations working to implement those principles in practice.

For additional information, please refer to our flyer. The link to the online application will be available in September 2013. Presentation slides are also available from the Intensive Seminar Information Session held at HBS on September 8, 2010.

Case Studies

The Institute for Strategy and Competitiveness (ISC) at Harvard University is developing a growing body of case studies on health care delivery. These case studies, set in the United States and abroad, provide detailed examples of the strategic, organizational, or process choices involved in moving towards value-based care delivery models. These cases provide a rich understanding of how individual actors can drive change and improve patient outcomes.

All ISC case studies are available for download or in hard copy via Harvard Business Publishing.

Completed Case Studies

• ThedaCare: System Strategy
  Sachin H. Jain, Michael E. Porter
  Over the 1980s and 1990s, America's changing health care payer environment resulted in mergers of numerous community hospitals into hospital systems. Based in Appleton, Wisconsin, ThedaCare stood out among community hospital systems in its pursuit of service rationalization, clinical quality improvement, and value-based delivery. Driven by determined leadership, ThedaCare began site-based service line rationalization and introduced innovative care delivery models. ThedaCare is a metaphor for the challenges of transforming American community hospital systems. Can be used to teach: the evolution of structure, organization, and strategy of U.S.-based community hospital systems; integrated practice units and care cycles; management of health care quality improvement processes; challenges in diffusion of care delivery innovation; and cost transparency and quality measurement.

• The West German Headache Center: Integrated Migraine Care
  Michael E. Porter, Clemens Guth, Elisa Dannemiller
  Describes the joint efforts of the German health plan KKH and Essen University Hospital to develop an integrated practice unit (IPU), and the West German Headache Center's efforts to improve the quality of migraine care. Provides an overview of the German health care system detailing its provider, health plan, and reimbursement structure. Following new legislation in 2004, which allowed health plans and selected providers to contract outside of the regular group purchasing scheme, KKH and Dr. Deiner of Essen University Hospital developed a novel delivery structure for migraine care. Challenges and hurdles to implementation are described for both the health plan and the IPU. Provides detailed data to allow students to evaluate success, identify current challenges, and recommend improvements to the integrated care system.

• Commonwealth Care Alliance: Elderly and Disabled Care
  Michael E. Porter, Jennifer F. Baron
  Individuals enrolled in both Medicare and Medicaid, known as dual eligibles, are among the highest-cost beneficiaries in the US. Commonwealth Care Alliance, a small nonprofit insurer and care delivery system in Massachusetts, operated under a public demonstration program designed to provide comprehensive coverage and care for the elderly dual eligible population. Led by Dr. Robert Master, Commonwealth Care Alliance worked with its contracted providers to implement and support a care delivery model that would allow as many members as possible to live independently outside of nursing homes. The case examines Commonwealth Care Alliance's insurance and care delivery approaches amidst a changing policy environment and various resource constraints.

• The University of Texas MD Anderson Cancer Center: Interdisciplinary Cancer Care
  Michael E. Porter, Sachin H. Jain
  In 2006, University of Texas MD Anderson Cancer Center was an internationally leading institution for cancer care, education, and research. Since 1996, it had successfully reorganized itself from a cancer hospital that was physically organized around clinical specialties into one what was organized into disease-based integrated practice units called multidisciplinary care centers. These units were supported by a new construction project that had created new disease-specific facilities and a widely-supported administrative plan in which physicians reported both to leadership of specialty-based academic departments and disease-based clinical centers.

• Brigham and Women's Hospital: Shapiro Cardiovascular Center
  Michael E. Porter, Robert S. Huckman, Jeremy L. Friese
  Considers the situation facing Gary Gottlieb, president of Brigham and Women's Hospital (BWH), prior to the opening of BWH's integrated cardiovascular center. This case allows students to develop an appreciation of the strategic, financial, organizational, clinical, and physical aspects of integrating health care delivery around specific categories of disease. It provides an opportunity to evaluate BWH's approach to integration along all of these dimensions and to identify the nature of the tradeoffs that hospitals--specifically, academic medical centers--face as they attempt to create disease-specific models of integrated care.

• In Vitro Fertilization: Outcomes Measurement
  Michael E. Porter, Saquib Rahim, Benjamin Tsai
  As of 2007, there were very few examples of widespread measurement and reporting of health outcomes, a critical quality measure. In-vitro fertilization clinics have been required to report their patient's health outcomes since 1995. The protagonist of the case, Dr. James Goldfarb, faces a number of challenges. As the medical director of a nationally-renowned fertility program at the Cleveland Clinic, he must run an efficient and effective practice that draws patients from both the surrounding area and from around the world. As a leader of the Society for Assisted Reproductive Technology, he must contribute toward the continuing evolution of the practice of in-vitro fertilization and ensure that the outcome measurement system is creating proper incentives and delivering timely, accurate, and useful information to patient, physicians, and researchers.

• Pitney Bowes: Employer Health Strategy
  Michael E. Porter, Jennifer F. Baron
  Pitney Bowes, a Fortune 500 mail and document management firm, offered its first health plans in the years following World War II. Over the ensuing decades, Pitney Bowes adapted its approach to employee health amid rising health care costs, shifting employer attitudes towards health benefits, and a rapidly changing policy environment. By 2008, the firm was widely regarded as an innovator in employee health, having dedicated substantial time and resources to its health benefits under the leadership of then CEO Michael Critelli and Corporate Medical Director Jack Mahoney. The case provides an overview of the history of employee health benefits in the U.S. and at Pitney Bowes. The range of health plans Pitney Bowes offered to employees in 2008, as well as the firm's contracting policies with commercial insurers and self-insured plan administrators, are examined in detail. Pitney Bowes health and wellness programs are also described, enabling an analysis of the firm's overall employee health strategy in 2008 and a discussion of where Pitney Bowes should focus its attention moving forward.

• The Cleveland Clinic: Growth Strategy 2012
  Michael E. Porter, Elizabeth O. Teisberg
  Cleveland Clinic's health care services are internationally renowned for quality. In 2012, strategic progress on value-based health care delivery is evident many dimensions. The Clinic is making strides in integrating care delivery cycles throughout northeast Ohio. This extends initiatives begun in 2007 that began restructuring the entire organization into teams defined around patient needs, rather than traditional medical specialties. "Patients First!" takes shape as the teams measure and report outcomes, coordinate care and develop processes to support improving value for patients and develop IT systems to support measurement and coordination. In addition to restructuring care delivery in the hospitals and throughout northeastern Ohio, The Clinic has investments, facilities and staff in several other states in the U.S. as well as in Canada and Abu Dhabi. Students can explore strategy transformation, systems integration, geographic expansion, the process of introducing new measurement approaches, alignment of activities with strategic goals, and issues in leading change both within a company and across an economic sector.

• Global Health Partner: Obesity Care
  Michael E. Porter, Zayed M. Yasin, Jennifer F. Baron
  Global Health Partner was founded in 2006 as a privately owned health care provider in Sweden serving both public and private paying patients. In contrast to most providers in the country, GHP organized around specific service lines where it saw the potential to provide the most value. This case details the GHP approach to both Spine Care and Obesity Care demonstrating the power of specialization for quality improvement as a basis for competitive advantage. Students will examine the organization of integrated multidisciplinary care, the impact of volume on learning and efficiency, and the importance of demonstrating quality through outcomes reporting. The case also provides a window into the Swedish Health Care System.

• Partners In Health: HIV Care in Rwanda
  Michael E. Porter, Scott Lee, Joseph Rhatigan, Jim Yong Kim
  In 2005, Partners In Health (PIH) was invited by the Rwandan Ministry of Health to assume responsibility for the management of public health care in two rural districts in Eastern Rwanda and create an HIV treatment program at these sites. PIH successfully implemented a comprehensive program focusing on 4 principles: health systems improvement, HIV prevention and care, accompaniment and social and economic support. By January 2007, the Rwinkwavu site had conducted 67,137 HIV tests and provided antiretroviral therapy to more than 2000 patients, of which, fewer than 1% had been switched to second-line drug regimens, 3.8% had died and only one patient had been lost to follow up. A costing anaylsis done by the Clinton HIV/AIDS Initative suggested that the model could feasibly be spread to other districts. Dr. Agnes Binagwaho, Executive Director of Rwanda's National AIDS Control Commission and her colleagues in the Ministry of Health are contemplating how the program could be improved and whether it should be expanded nationally.

• Dartmouth-Hitchcock Medical Center: Spine Care
  Robert S. Huckman, Michael E. Porter, Rachel Gordon, Natalie Kindred
  The Spine Center at Dartmouth-Hitchcock Medical Center is a multidisciplinary unit that offers patients suffering from spinal problems a single point of contact to access a range of providers including orthopedic surgeons, neurosurgeons, neurologists, medical specialists in physical medicine and pain management, mental health providers, and occupational and physical therapists. The Center was created to address what its founder, James Weinstein, M.D., saw as the uncoordinated and inefficient delivery of spinal care in the United States. The Center emphasized using non-surgical treatments (e.g., physical therapy and exercise, behavioral modification, pain-relieving drugs) as either a complement to, or substitute for, surgical procedures, and actively engages patients in the process of determining what type of care to pursue. In addition, Weinstein and his staff collected data from the Center's clinical practice to conduct academic research on the outcomes and cost-effectiveness of various approaches to treatment. The case allows for a critical analysis of the Spine Center's unique approach to care delivery and provides an opportunity to examine the applicability of this model in other clinical areas.

• The Joslin Diabetes Center
  Michael E. Porter, Scott Wallace, Elizabeth O. Teisberg
  The Joslin Diabetes Center in Boston, Massachusetts is a leading center for diabetes care, clinician training, and research. The incidence of diabetes is rising precipitously worldwide, challenging quality of life with its complications and rapidly accelerating health care expenditures for employers and governments. The Joslin's multispecialty, team-based care and patient education programs provide opportunities to examine integrated practice units, early-stage and preventive care, and clinical coordination along the full care cycle. The focus on diabetes also enables discussion of what services need to be included in integrated practice units serving patients with complex, chronic diseases. However, despite its renown, the Joslin's clinical operations lose money, raising the challenge of how to align financial success and clinical success in health care delivery. The case can be used to teach strategy in health care delivery, value creation, outcome measurement, reimbursement, and strategic alliances.

• Koo Foundation Sun Yat-Sen Cancer Center: Breast Cancer Care in Taiwan
  Michael E. Porter, Jennifer F. Baron, C. Jason Wang
  Taiwan's Koo Foundation Sun Yat-Sen Cancer Center has developed an integrated, team-based care delivery model for breast cancer care that is being expanded to other cancer types in 2009. A decade earlier, President and CEO Dr. Andrew Huang and the Center had worked with the Taiwan National Health Insurance system to create a pay-for-performance reimbursement program for breast cancer care that has since been adopted by five other providers. The program issues capitated, per patient base payments for breast cancer care with bonus payments based upon provider reporting and performance on a set of quality measures. This case allows readers to examine health care provider strategy, development and implementation of bundled reimbursement, integrated care delivery, quality measurement, and Taiwan's universal health care system.

• Ledina Lushko: Navigating Health Care Delivery
  Sachin H. Jain, Michael E. Porter, Fatima Akrouh, Carolyn A. Daly
  Ledina Lushko was diagnosed with Adrenal Cortical Carcinoma in 2008 and sought care at a highly regarded medical institution in the United States. This case lays out her journey through the health care system in detail and the considerable degree of effort involved in finding appropriate care. It is meant not to illustrate good or bad care but to allow for reflection on the nature of the current health care delivery system and to provide a starting point for discussion.

• Children's Hospital of Philadelphia: Newtwork Strategy
  Michael E. Porter, Carolyn A. Daly, Andrew Dervan
  In 2009 Children's Hospital of Philadelphia (CHOP) had been recognized as the best children's hospital in the country for six years in a row, but leadership saw CHOP as more than the large main campus in Western Philadelphia. Beginning in the 1990s, CHOP had created a large network of Primary Care Providers, Specialty Care Centers, Ambulatory Surgery Centers, and community hospital affiliations. CHOP leadership wanted to ensure that the quality they had demonstrated at CHOP would translate out to these facilities, and more, that the combination of many parts could actually work together to provide even better care than the main hospital could do on its own.

• Highland District County Hospital: Gastroenterology Care in Sweden
  Michael E. Porter, Jennifer F. Baron, Martin Rejler
  Sweden's Highland District County Hospital, similar to a community hospital in the US, undertook a major restructuring to integrate care delivery for medical conditions served by the Department of Medicine. Each subspecialty within the Department would form a single, co-located unit with its own budget that encompassed both inpatient and outpatient care. This case examines the experience of the Highland Gastroenterology Unit, led by Dr. Jörgen Tholstrup, and compares the delivery model for inflammatory bowel disease in 2001 and 2009, before and after the reorganization. The case can be used to examine health care provider strategy, integrated care delivery, and quality measurement. The case also profiles Sweden's single-payer health care system, allowing for a discussion of national health systems and health policy.

• The UCLA Medical Center: Kidney Transplantation
  Michael E. Porter, Jennifer F. Baron, Jacob M. Chacko, Robin Tang
  In 2010, organ transplantation remained among the few sets of medical conditions in the US for which bundled payments were a dominant reimbursement model, and for which patient health outcomes were universally measured and reported. In 1986, UCLA Medical Center was approached by Kaiser to develop a new bundled pricing approach to kidney transplant care that was quickly adopted by many payers and providers for various transplant types. This case study examines the history and current state of care delivery, reimbursement, and measurement for the UCLA Kidney Transplant Program, among the nation's highest-volume transplant providers. The UCLA Kidney Program is an interdisciplinary unit that involves clinicians from multiple Departments and engages in continuous care management throughout the often protracted transplant care cycle.

• Schön Klinik: Eating Disorder Care
  Michael E. Porter, Emma Stanton, Jessica A. Hohman, Caleb Stowell
  The Schon Klinik is a private, for-profit German hospital group trying to establish itself as a premium health care provider in a competitive German market. The case details Schon Klinik's founding, its early focus on measurement and improvement, and the design and implementation of a system-wide structure for measuring and reporting actual health outcomes. The case details the care cycle for eating disorder patients and highlights the role outcomes measurement has played in improving eating disorder care over time. It ends with a discussion of Schon's innovative bundled reimbursement models and challenges the reader to explore how to develop new pricing and care delivery models that encourage integration of care around patient medical conditions. The case also discusses the German health care system, its regulatory constraints, and Schon's attempts to change the paradigm of competition in the sector.

• Reconfiguring Stroke Care in North Central London
  Michael E. Porter, James Mountford, Kamalini Ramdas, Samuel Takvorian
  In 2006, surgeon Ara Darzi identified several key areas, including acute stroke care, for improving health care across London. In response to his seminal call to action, stroke care was reorganized around eight hyper-acute stroke units covering London's five sectors, replacing the more than thirty units that previously delivered acute stroke care. This case profiles the roll-out of the new care delivery model in North Central London, where acute stroke care had previously been fragmented among five acute hospital trusts with varying care resources, capacity, and protocols. In the new model, stroke care would be delivered across facilities in an integrated fashion, with a single hyper-acute facility designated for care of the most acute and severe cases.

• Boston Children's Hospital: Measuring Patient Costs
  Robert S. Kaplan, Mary L. Witkowski, Jessica A. Hohman
  The case describes two pilot projects on applying activity-based costing to measuring the cost of treating patients. It presents process maps and financial data relating to the processes used during (1) an office visit to a plastic surgeon for three different diagnoses and (2) application and removal of three different casts in the orthopedic cast room. Students calculate and compare the costs and margins of the three procedures at the two different sites using the hospital's existing cost system and a proposed new system based on time-driven activity-based costing.

• Great Western Hospital: High-Risk Pregnancy Care
  Michael E. Porter, Emma Stanton, Samuel Takvorian
  Great Western Hospital (GWH) is a community hospital in Wiltshire, South West England and one of England's largest maternity providers; responsible for delivering over 9,000 babies per year. The case discusses the efforts of Dr. Harini Narayan, consultant obstetrician and gynecologist, to reorganize antenatal care delivery at GWH. Rather than treating high-risk pregnancies as a homogenous group, Dr. Narayan pioneered the development of eleven condition-based, high-risk clinics, led by dedicated multidisciplinary teams of physicians, midwives and nurses. The case profiles the Multiple Pregnancy Clinic in particular, and its impact on perinatal indicators and outcomes.

In Process

• Park Nicollet Health Services: Diabetes Care
• International Diabetes Center at Park Nicollet
• Novo Nordisk
• Aetna: Health Insurance Strategy
• Schon Klinik: Measuring Cost and Value

Invitation to Health Care Faculty

We would be pleased to collaborate with faculty interested in teaching any of the Institute's health care case studies or other Value-Based Health Care Delivery material. To learn more about our curriculum and discuss how it might be used at your school, please contact Professor Porter (mporter@hbs.edu) or Institute Senior Researcher Caleb Stowell (cstowell@hbs.edu).