February 04, 2019
The Challenge of Defining Value in Health Care
The recognition that patients are the ultimate stakeholders in healthcare is driving several ongoing efforts to define value, but the question remains: Which patients are we talking about?

One of the challenges in transitioning from volume-based payments to value-based systems is that to achieve value, you have to be able to define value. Volume-based systems are comparatively easy: A test costs this much, a procedure costs that much, an office visit this much, and so on.

Value is a different story. For starters, it means different things to different groups, and, within those groups, different things to different subgroups and individuals.

So how should value be defined?

“For healthcare organizations, value can be defined by resource utilization,” says Jean-Manassé Theagene, CEO and President of 360Medlink in Montreal, Canada. “For healthcare providers, value can be found in workflow management and clinical outcome improvements.”

But, he adds, “for patients, … value is tied to the experience and outcome of care.”

That recognition—that patients are the ultimate stakeholders in healthcare—is driving several ongoing efforts to define value, but the question remains: Which patients are we talking about?

Broadly speaking, “value-based care means care where the clinical benefits outweigh the risks and the cost,” according to Jennifer Bright, the executive director of the Innovation and Value Initiative, and Mark Linthicum, the organization’s director of scientific communications. “[But] clinical benefits, risks, and costs vary across patients.” For example, some patients, given the option, will choose the efficacy of a powerful drug, regardless of side effects, while others, may choose reduced efficacy and fewer side effects.

Additionally, value is often calculated on the basis of benefits for the “average” patient. Providers may not know the value of a given treatment in relation to certain age groups, genders, ethnicities or disease subtypes, because such data may not be recorded in clinical trials. “Thus, the neat ‘answer’ regarding the value of a treatment often overlooks vital information,” say Bright and Linthicum.

Changing value

There’s also the fact that value in healthcare is dynamic. “For many interventions, evidence continues to accrue and indications evolve,” say Robert W. Dubois and Kimberly Westrich of the National Pharmaceutical Council. As such, a static assessment that fails to accommodate “’moving targets’ of evidence and innovation,” could lead to outdated or misleading findings.

“Patients should be actively involved both in the development and refinement of frameworks and in the assessment of value,” they add, “[but] none of today’s frameworks have comprehensively and effectively included patients in this fashion.”

Moving forward

The Patient-Perspective Value Framework (PPVF), an ambitious joint project of the think tank FasterCures and the consulting firm Avalere, represents an ongoing effort to address the perceived failure to put patients front and center when it comes to calculating value. “It’s time to stop treating this as a lofty, unattainable goal and instead embrace a fully defined framework for measuring value through the patient’s eyes,” say representatives from the two organizations.

The approach is built around patient preferences, including values, needs, goals, expectations and openness to financial trade-offs. It’s designed to address the “whole patient,” they say, focusing not just on clinical benefits, but also on quality of life, complexity of regimen, efficacy and effectiveness, side effects, adverse events, and complications. Further, they say, you can’t assess value without considering financial costs to patients and their families. So the PPVF approach also considers the financial impact of numerous factors, including deductibles, copayments, associated supportive care, lost productivity and travel costs.

Meanwhile, to address individual differences, it promotes the use of nontraditional data sources (such as clinical registries or administrative/EMR repositories) to determine whether evidence of value exists for specific subgroups even if a treatment is considered to have marginal value for the population as a whole.

“As the U.S. healthcare system transitions to value-based payment, it is imperative that we get the value definition right and measure what truly matters to the patient,” says Josh Seidman, senior vice president in Avalere’s Center for Payment and Delivery Innovation.

The value of scribes

Patients also place a high value on the interactions they have with their providers. One study found that patient-satisfaction scores were strongly associated with what the researchers called clinician “gaze time.” In other words, patients wanted their physicians to look them in the eye while they talked, instead of looking down at their laptops. Another study found that when EHRs were heavily used during patient interactions, only 48% of patients gave high satisfaction marks. But when EHRs were barely touched, those rates zoomed to 81%.

Along with boosting productivity and revenue for providers, medical scribes represent a strong value proposition for patients. By handling data entry (as well as many other administrative tasks), they free providers from the shackles of EHRs and help give patients the reassuring feeling that their providers care enough to look them in the eye while discussing vitally important matters.