“Value” is the focus right now in American health care. Payers like Medicare and private insurers are placing great emphasis on it, as are hospitals and doctors’ offices needing to satisfy the demands of those payers to get paid. But the focus on value in the present system is centered on reforming payment and lowering costs almost exclusively, rather than enhancing the patient experience, and involves unproven approaches like “bundled payment” and “pay for performance”, in which doctors and hospitals are financially incented to fixate on efficiency in how they deliver care. In short, right now “value” means figuring out ways insurers can save money and providers cannot lose money.
The emphasis on value in terms of efficiency and payment reform isn’t trickling down in positive ways to individual patients. Insurance premiums continue to rise, taking more dollars out of patients’ paychecks to cover the care they need. Health insurance is covering less in that many of us pay higher deductibles and co-pays in our plans for services such as physical therapy, mental health care, and emergency care. Many people have annual deductibles of thousands of dollars that must be paid before having any specialty care covered.
Americans pay more and yet have serious access problems in primary care, long-term care, and much specialty care. Wait times to see all kinds of doctors are increasing in most areas of the country. To deal with this, in American primary care patients are guided into undifferentiated, highly transactional forms of service delivery that may be cheaper but are less comprehensive in the services offered and impersonal, involving fast-food care provided through web-based apps, big box stores, and urgent care centers. These sources of care often practice their medicine according to “cookbooks” of standardized clinical guidelines using high-turnover providers, giving us fewer moments of the relational excellence so important in high-quality health care.
We also continue to lose choice as we are captured by large health care delivery systems, now turning up in most areas of the country as different providers consolidate and form de facto monopolies that force us to see only their physicians, go to their facilities, and use their labs and imaging services. This makes patients prisoners of a given health care organization. That is not real value for patients, although those very same systems will try and tell you it is, even as the prices they charge continue to rise, and the access problems get worse in those same systems of care. I tried to switch my primary care doctor recently from one large Boston-area health system to another. The new system told me that I would have a difficult time getting “referred out” to any specialists, even ones I was already seeing, in the system of which I was still a part. We keep everything in house, they told me. Good for their business, not so good for me.
A value definition controlled by insurers, providers, and big employers looking to maintain profit margins does something else bad for patients. In measuring value through the heavy use of standardized performance measures to judge their own worth to those paying them, doctors and hospitals work harder on comparing themselves to each other, which leads to gaming incentive systems that possess too many superficial and self-reported quality measures It also means providers spend less time measuring how they are meeting our unique needs, wants, and preferences as individual patients. This makes our health care feel more impersonal. It also encourages health care delivery organizations to view insurance plans, accreditors, and Medicare as their chief customers, rather than us.
Focusing on value for patients requires meaningful change in the health care industry. Large delivery systems that dominate geographic areas must be regulated more effectively to provide patients with greater choice and timely access. Provider competition needs to be encouraged, not squashed. Payers must construct flexible reimbursement approaches that reward, in meaningful ways, patient satisfaction and relational excellence between providers and patients. Right now, that’s not the case. Most importantly, patients must be activated as true consumers and force the system to be accountable to them. This accountability comes in many forms. It can involve pushing providers to be transparent about the prices they charge for different services; and then helping us to comparison shop and make decisions using that information. It can involve things other industries and a few innovators in health care use such as money-back guarantees and the use of Yelp-type ratings systems, which we control.
Of course, these things would only be a start on the road to pursuing “value” as a more patient-driven concept within the industry. But once we realize that such a vague word can mean anything we want it to mean, and that patients rather than the industry should define it, it will get easier to do.
Timothy Hoff, PhD is Professor of Management, Healthcare Systems, and Health Policy at Northeastern University in Boston, A Visiting Associate Fellow and Visiting Scholar at Oxford University, and author of the new book, “Next in Line: Lowered Care Expectations in the Age of Retail- and Value-Based Health”, published by Oxford University Press.