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By Casey Ross Nov. 29, 2017
Value is medicine’s mantra of the moment.
It is the centerpiece of efforts to reform payment and change the way medicine is delivered. Backers of the value movement believe the entire medical system — and every transaction within it — must be based on this seminally important five-letter word.
But a survey released Wednesday by the University of Utah shows that, in health care, value has no universal meaning — 88 percent of doctors equated value with quality care, while patients and employers provided a more nuanced definition, mixing in measures of cost, customer service, and worker productivity.
The lack of consensus is not merely a philosophical matter. It is a huge stumbling block in the effort to deliver more bang for the buck in American health care, said University of Utah chief medical quality officer Dr. Bob Pendleton, who worked on the survey and argues the term value has become political “propaganda” in medicine.
“It seems to be used in any way people want it to be used, to fill their own agendas,” he said. “The conversation around value is driven by large lobby groups — hospital associations and large corporate medical groups. What’s missing is the voice of practicing doctors, patients, and employers.”
“What’s missing is the voice of practicing doctors, patients, and employers.”
Dr. Bob Pendleton, University of Utah
The national survey, conducted by Leavitt Partners, collected responses from 5,031 patients, 687 physicians and 538 employers. All parties agreed the cost of health care is too high. But they gave cost different levels of significance in their value equations. Doctors tended to focus almost entirely on quality measures. But employers said cost is a matter of primary concern, with nearly 60 percent ranking it as a key component of value.
Patient definitions of value were divided among quality, cost, convenience, and customer service. When asked to choose statements that reflect what they value, the one patients selected most (45 percent) was that out-of-pocket costs must be affordable.
Dr. Lisa Simpson, chief executive of Academy Health, a research and policy group that was not involved in compiling the survey, said it will take more clarity around costs and quality to get patients and doctors on the same page.
She said neither party knows what medical services cost, and quality measures often miss the mark, focusing on technical definitions or process issues rather than whether a knee replacement patient can climb stairs or lift a grandchild.
“You want to measure functional outcomes,” Simpson said. “It’s not just, ‘Did you get better? Or did you get an infection and get re-hospitalized?’ It’s more about whether you were able to return to function.”
In the survey, 76 percent of physicians said they consider cost when making treatment decisions. But Pendleton said physicians lack access to accurate pricing information and are often flying blind in those discussions.
Furthermore, he said, the average doctor takes care of patients with 14 or 15 different insurance plans, adding yet another layer of complexity. “Somehow we have to create a path where in the clinic those costs can become an effective part of the conversation,” he said. “Right now, they are certainly very opaque.”
The disconnect is becoming even more pronounced at a time when patients are paying higher deductibles. Part of the rationale for those higher deductibles is that they turn patients into smart shoppers who carefully consider what they buy.
But Allan Baumgarten, a health care consultant and researcher, said providers have an incentive to obscure cost information from patients, so they can steer them into settings where they can charge added fees. A common example is a provider that schedules a lab test in a hospital where it can charge a “facility fee” that often adds hundreds of dollars to the bill.
“Providers systems will cloak that information so that it’s not readily apparent to the consumer,” Baumgarten said.
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Among doctors who answered the survey, 73 percent expressed dissatisfaction with the prices patients pay for medical services. Fifty-five percent said one of the most important components of value is selecting the most appropriate test or treatment for the patient.
Pendleton said in determining appropriateness, physicians must consider clinical and cost factors at the same time, so that ordering an MRI for a patient with low back pain is done in a calculated way, and not as a matter of course.
“For that patient with low back pain, there is more and more evidence to say a trial of physical therapy and over-the-counter ibuprofen actually has as good, if not better, outcomes,” he said. “And if we look at the cost of that, it’s a tenth or a hundredth of some of the other options.”
National Technology Correspondent
Casey covers the use of artificial intelligence in medicine and its underlying questions of safety, fairness, and privacy. He is the co-author of the newsletter STAT Health Tech.
I think that part of society’s general low health literacy is a lack of understanding what “good” outcomes actually are. If the patient expects rapid and thorough resolution of a problem after surgery or other intervention, they are going to be dis-satisfied most of the time. That will effect their perception of “value”. “Good” outcomes as defined by clinicians and researchers are different that a return to some “normal” state.
Good discussion of what constitutes quality, which is one side of value. But there is always a “cost” or dollar amount in the value equation. One thing the article misses is that in some case, this is the cost of the service (payer perspective) and in some cases it is charges (patient perspective). There is usually little correlation between the two.
The “customer triad” is cost, convenience, and quality. Isn’t it hilarious that the Value definition pushed on the system (by payers) for the past 9 years has been Value=Quality/Cost? Payers (including the Federal Government) have never wanted the patient’s convenience to be considered. Further, the single-payer system favored by many on the left imposes long waits and rationing–the opposite of patient convenience. So, which is it going to be–a system responsive to customers, or a single-payer/low cost system? It can’t be both!
Equating value with affordability is an oversimplification. In my own case:
-first psoriasis drug costs $15,000 and gave 55% skin clearance.
-second psoriasis drug costs $45,000 and gave 95% skin clearance.
If you ask me which drug has better “value” it’s a no brainer.
A treatment that the patient can’t afford to utilize has exceedingly little value to that patient.
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