Healthcare value is in the eye of the beholder

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In chasing “value” as the ultimate goal of healthcare reform, providers may misunderstand that patients and physicians see value in different ways, creating barriers to true reform, according to an article published March 7 in the New England Journal of Medicine.

Comparing the concept of searching for value in healthcare to the notion of inattentional blindness—discussed previously in Health Imaging—author Lisa Rosenbaum, MD, of the University of Pennsylvania in Philadelphia, explains that value depends on who is looking and what they expect to see.

“The value narrative effectively splits patients and physicians into separate teams,” wrote Rosenbaum. “When we focus on physicians, creating value means mitigating overuse, increasing efficiency, and providing incentives to deliver evidence-based care. When we focus on patients, creating value means enhancing patients' experience, honoring patient-centeredness, and catering to outcomes that matter to patients.”

For example, patients may ask physicians for tests to achieve peace of mind about an illness even if no evidence exists that these tests produce better outcomes. A physician-centric view of value would see little value in administering a costly test in such a situation, but a patient-centered view acknowledges the psychological benefit patients experience from undergoing such a test, explained Rosenbaum.

“Rewarding value when it comes to physician behavior is easy when we are talking about measures, such as prescribing aspirin after a myocardial infarction, that clearly confer better health,” she wrote. “But as we move away from a robust database into the area where most of medicine is practiced, the line between objectively necessary health measures and the type of care patients expect and value becomes blurred.”

This is particularly true in imaging, noted Rosenbaum, since imaging tests can often be adopted in practice without a robust demonstration of clinical efficacy. As a result, imaging technology can outpace an understanding of how best to use it. She praised efforts of the Choosing Wisely campaign in identifying tests that do not need to be performed routinely, but acknowledged that for many tests and indications, detailed data are lacking.

Rosenbaum suggested reframing value in such a way that decisions incorporate patients' values to improve overall care, even if evidence-based decision making may seem to be undermined and imaging increases. For instance, showing a patient an image of his or her coronary plaque may not have any direct diagnostic benefit, but may motivate them to reduce risk factors. Head CTs and repeat mammograms may not be warranted based on evidence, but if they ease the minds of patients and lead to happier, more productive lives, they may become necessary.

“If we want to simultaneously improve quality and cut costs, we must first stop creating incentives that effectively split patients and physicians onto different teams,” wrote Rosenbaum. “We must acknowledge that shared decision making is just that: shared.”