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Seeing Value From the Patient’s Perspective

“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.

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HealthViewX
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HealthViewX

Today health care is moving from fee-for-service to value-based care. Patients see value in the care provided. Providers are looking for solutions to provide quality care for their patients. Patient Referral Management Solution helps providers like – FQHC’s, enterprise hospitals, imaging centers, specialty clinics to provide quality care and also increase providers overall operation’s efficiency.

Pesto Sauce
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Pesto Sauce

Third party payors and a closed highly regulated system like the one you’re privy to in Massachusetts want “value” to consist of the basic medical service at a decent price. They have to squeeze every dime out of you and not refer you out because of payroll, insurance, compliance costs, etc. There is no one invoice, as you know every Tylenol and every test is itemized and billed separately, thus ballooning costs as in a cardiac cath. where the cardiologists’ fee is $1500 but the 23 hour stay in hospital is $45,000. The problem lies in the perception of value… Read more »

Barry Carol
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Barry Carol

As a patient, I have two separate perspectives on this subject. First, I have an economic interest in finding the lowest price at acceptable quality / competence for any given service, test or procedure that can vary widely in price even in the same city or town. I’m thinking of MRI’s, CT scans, screening colonoscopies and the like in this context. Even if my insurer is paying the entire bill, I want this in order to mitigate growth in the cost of my insurance premium. I also want to stay away from expensive hospitals if care can be delivered safely… Read more »

Hootsbudy
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I would like to see a “consensus evolve among payers and across society around the value of a human life which can be then translated into cost per quality adjusted life year (QALY) for expensive surgeries and specialty drugs as Uwe Reinhardt described…” As he wryly suggested, the idea of QALY can vary widely. Is the life in question yours or mine? Is it for a Democrat or a Republican? He someone in my family or a stranger in the ER? What is the life expectancy? The number of unanswerable subjective questions runs from ridiculous to sublime, making QALY a… Read more »

pjnelson
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pjnelson

One issue is the lack of any researched based and non-invasive test to assess the resiliency of a person’s baseline homeostasis at one point in time and how that is changes over time to predictably define futility. It is of interest that human health research is based on the time dimension. There is another testing realm of knowledge defined as the Frequency domain. Biologic control systems are very complex and frequently operate with non-linear functional characteristics, the bane of diagnostic certainty for physicians. Other than for electroencephalographic patterns, the use of the Frequency Domain has not occurred as a basis… Read more »

Barry Carol
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Barry Carol

It is not my intention for a specific QALY limit to be a rigid metric especially since hospital and physician operating costs vary quite a lot around the country. . It should be more of a guideline. For example, a payer might say it will pay for the treatment if the QALY metric is at or below X. If it’s between 1.01X and 1.50X or even 2.0X, it will evaluate whether or not to pay on a case by case basis. Or, it will establish protocols for which patients get treatment and which don’t similar to what we already do… Read more »

LeoHolmMD
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LeoHolmMD

“It can involve pushing providers to be transparent about the prices they charge for different services…”

Thanks for your discussion. Consider that providers really have no control over the transparency you are suggesting. Payers forbid this type of transparency as do large health systems. I would gladly have prices posted tomorrow in the office.

Hootsbudy
Member

No discussion of “value” should overlook the wisdom of Ewe Reinhardt on this subject. He covered it quite well in a 2016 meeting of health care professionals. I made a clip of his delightful portion of the event which appeared on C-SPAN last November. Dr. Hoff said “such a vague word can mean anything we want it to mean” and he’s correct.. Listen from about the six minute mark for ten minutes or so for the gist of Reinhardt’s message which is the same but more entertaining as he illustrates the point. https://www.c-span.org/video/?c4691782/uwe-reinhardt-based-healthdare I suppose it’s a foregone conclusion that… Read more »

LeoHolmMD
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LeoHolmMD

Great discussion by Ewe. Thanks.

Toolate
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Toolate

Well said right up to the part about the usefulness of Yelp like reviews. Heck yelp doesn’t even help me find good restaurants