Thinking about Value
Thinking about the value of care is a very hot topic. Everyone: patients, doctors, insurers, pharmaceutical companies is weighing in and almost everyone has a somewhat different perspective on the issue. We all agree that health care costs are out of control, and that some better systems need to be developed to deliver the best and most valuable care to patients.
This gets interesting from the very start as value is differently understood and defined by different players. Are we talking about cost or the expected benefit of a treatment or some combination? Understandably, many oncologists feel awkward having this conversation with patients, and many of us feel equally awkward in discussing our finances with our doctors. It is no longer true (if it ever really was true) that only people with low incomes and/or less than comprehensive insurance can run into trouble. Even the "Cadillac" insurance plans are charging higher deductibles and co-pays. I met with a woman this morning whose GI doctor has just prescribed a new treatment for her that will cost her $24,000 a year beyond what her insurance will cover--and this is without any certainty that it will even be helpful. Note that her dilemma is not a cancer drug; this problem is much broader than that.
This is a prelude to the best discussion about all of this that I have seen and, even better, it was written by an old friend and oncology social work colleague, Diane Blum.
How Physicians Can Explain Value to Patients
There is now a sustained focus on ensuring value in health care, although the definition of “value” varies widely among policy makers and health care experts across national boundaries. Earlier this year, the Obama administration announced its goals for a shift in Medicare from a system that reimburses volume of interventions to one that uses financial incentives to promote higher-value care. Private insurers and Medicare demonstration projects are focusing on value, and Secretary of the Department of Health and Human Services (HHS) Sylvia Mathews Burwell acknowledges that HHS hopes this shift will become the standard throughout the country and will not be limited to Medicare.
Explaining value to a patient in this new environment is complex, as each individual’s perspective
influences their perceptionof value. The most fundamental understanding of value is that it relates the quality of care to the actual cost of the care, or as Warren Buffett is frequently quoted, “Price is what you pay; value is what you get.” A definition that looks at value more broadly was suggested by Scott Ramsey, MD, PhD, and Adam Schickedanz, MD, in 2010 when they wrote, “An intervention in cancer care can be described as having value if patients, their families, physicians, and health insurers all agree that benefits afforded by the intervention are sufficient to support the total sum of resources expended for its use.”2 This definition allows a look at the overall financial and psychosocial effects of care for a patient, family, and health care system, and not just the cost of the medical treatment.