Value-based healthcare is best defined as “good outcomes achieved efficiently” (Porter, 2009). What this means is relatively easy to define if we are using an abstract perspective, but much harder to define if we are being concrete. Let me be more specific about what I mean. It is easy for us to say that we want to achieve the best outcomes possible while spending the least, but what that actually means is an open question. Do we subordinate the former part of this judgment to the latter part, or do we subordinate keeping costs down to achieving the best medical outcomes? It seems likely that the answer is somewhere in the middle, and that we need to provide some care, and that will require spending money. Value-based healthcare requires an awareness that warehousing preventative care is a false savings. Preventative care, and especially ordinary preventative care, by whatever standard one chooses to use is straightforwardly better than curative care. Curative care is expensive, relative to the quality of life improvement that it provides. However, the healthcare system as it is currently privileges curative and acute care over preventive and chronic care, because the very poor have access only to acute care and may be willing to “roll the dice” by not seeking preventative care.
Value-based healthcare further requires that we understand exactly what sort of value is being provided. To use other language that may be more familiar from other contexts, value-based healthcare requires metrics (Porter, 2009). Let me give an example of what is meant by this. It has been asserted that value-based care requires the privileging of preventative over curative care, because preventative care is simply so much more efficient than curative care. But this is not an assertion that we can make simply off of intuitions. It may be the case, for instance, that the cost of getting the flu shot each year (a straightforwardly ordinary prophylactic measure) is greater than the cost of getting the flu multiplied by the probability of getting it. Of course, even in such a case, we might say that we should still encourage flu shots to distribute the cost of getting those shots and reduce the burden on the unlucky few, but that is not the same thing as saying that it is an efficient way of providing healthcare. That is, if the flu shot actually was too expensive to justify, on a value-based perspective in which healthcare value was the only concern (rather than the general societal goal of socializing costs), we might say that we don’t want to encourage the flu shot or even refuse to provide it. But what is important here is that we need metrics so that we can know, rather than intuit, which approach is more efficient.
The last definitional element of value-based care which I wish to address is that value assessment may have to be divided into sub-regimes rather than all groups compared (Porter, 2010). It is important to keep in mind that the goal of lengthening a life may be weighted very differently, for a 90-year-old patient, than it is for a 40-year-old or a 16-year-old, and that they have altogether different concerns. Further, it is important to keep in mind that value and efficiency need to be assessed in cohorts rather than all groups taken together. If this is not done, we will get some very strange results in terms of how efficient we are being; results that would suggest that an 80-year-old patient can be efficiently treated for plantar fasciitis with a goal of restoring the ability to run.
We now wish to address the evidence which supports value-based healthcare. In at least one important sense, this is a nonsense question. Because value-based healthcare is a framework for evaluating the actions we ought to take to improve healthcare, rather than itself being a set of recommendations, it does not appear that there is any meaningful way in which we can say whether or not value-based healthcare “works.” To assess whether a recommendation or set of recommendations works, we must bring in assumptions and value criteria from our regime of practice; assessing whether a regime of practice works requires that we answer questions that are entirely external to our task as care providers. However, one thing we can do is examine some of the reasons that we have for believing that a value-based healthcare system may push us in the direction of efficiently providing good care, even if we are not clear on exactly what definitions we should use.
The first advantage that the value-based healthcare paradigm has is the generally lower cost of preventative care (Porter, 2009). Although we did raise the point that it is impossible to say whether value-based care dictates a particular kind of preventative care without actually performing a quantitative investigation, we can point to the research that shows that preventative care generally accomplishes the same result (absence of a disease or condition) with less expenditure per case prevented or resolved. Even in the absence of hard research on a population level, we would therefore be able to say that value-based care’s recommendations “work” in that they are likely to point us towards practices that align with those that are already recognized as responsible healthcare.
The second important area of research to which I can point as evidence that the value-based healthcare perspective is a valid one is the research that has been done on quantifying, for the purposes of addressing efficiency, the value provided by a medical procedure, device, or treatment. The framework is the “quality-of-life-year,” and it functions by evaluating a utility function for the patient in terms of preferred life outcomes, with “alive and perfectly healthy” at 1.0 and “dead” at 0.0. Each year when suffering from a condition will be worth less than one complete “quality of life year” because the duration is multiplied by the utility function (Brown, Brown, Sharma, & Landy, 2003). This allows us to actually model the improvement in a patient’s life relative to the amount of money spent, and this is possible even in palliative care in which the goal is not to increase the length of the patient’s remaining years but rather to make them more enjoyable.
By way of conclusion, I wish to address the case of value-based care as it applies to the provision of pharmaceuticals. The $/QALY approach would, of course, strongly come down in favor of greater use of generic, rather than brand-name, drugs. It would also, I think, encourage us to reduce overprescription by a fair bit. The patient is not a customer in the ordinary sense; rather, the goal of a healthcare provider with respect to the patient is to improve the patient’s holistic well-being and quality of life. The goal is not patient satisfaction; there are cases in which “go away and tell me if it gets worse” is a perfectly acceptable response and is exactly what that value-based care approach would dictate. The overuse and overprescription of pharmaceuticals is, of course, only one small piece of the puzzle, but it is an important piece, and I believe that it is an example that illustrates the applicability of the value-based-care approach.
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