The term "high-value care" has become a staple in most healthcare conversations, but also many hospitals' marketing campaigns. Shouldn't high-value care be an implicit part of any healthcare organization? And what's more, how can consumers ever know the difference?
Before going further, it's interesting to take stock of high-value care's place in healthcare marketing and promotion. It's not often you see hotels advertising rodent-free rooms, banks plugging fraud-free credit cards or airlines touting their low crash rates. The mere mention of these violations of trust would taint consumer perception and possibly raise suspicion, a classic case of "the lady doth protest too much, methinks."
But many hospitals and health systems promote their services as "high-value," as if this somehow puts them above the sea of hospitals that aspire to deliver no-, low- or mid-value care. Aside from my coverage of healthcare fraud and abuse, I have yet to encounter a healthcare organization with such offensively modest goals. Though some may miss the mark on value, I'm not so sure it's a widespread aspiration to do so.
The definition of value, in this post at least, is that it equals quality (outcomes and safety) divided by cost. It's a simple definition, but tricky in that it's intangible, at least in the immediate sense. This is another reason it needs to be reigned in its use with consumers: They have a hard time identifying the value of their care. It's not perceptible.
You can see a rat in your hotel room, fraud on your credit card and, unfortunately, you can track plane crashes. But for the average consumer to "bust" their physician visit or medical procedure as low-value? It seems far-fetched. It's reasonable to assume many patients undergoing a blood test, CT scan or other procedure don't have the medical or economical expertise to determine whether this service is worth the money.
Overuse, or low-value care, can also be driven by patients' requests or demands, which can make the concept of high-value care one of those "not in my back yard" issues. People may support it for the country's healthcare system overall, but not today, here in this physician office, when it means my physician may question or avoid a screening, test or procedure that could ultimately benefit me.
So there is very little opportunity for the consumer, even the biggest of watchdogs, to catch a hospital or provider explicitly violating their claims of high-value care (like I said, short of fraud, abuse and medical malpractice). Poor quality and high prices are relatively simple to discern, and consumers are increasingly on the lookout for the latter, especially. But the high value claim is tough to dispel, which may be one reason why it's become so widely accepted and used. Few in the general public will argue with it.
That said, "high value" is something only the physician, if anyone at all, can prove. A roundtable from the New England Journal of Medicine and led by Atul Gawande, MD, writer and surgeon at Brigham and Women's Hospital in Boston, asked experts with three different perspectives to explain "low-value care." A stance that came up several times throughout the discussion is that determinations about value are ultimately meant to be made by physicians.
Bruce Landon, MD, professor of healthcare policy at Harvard Medical School, and professor of medicine and internist at Beth Israel Deaconess Medical Center in Boston, put it well:
"I don't think we should leave this conversation thinking that shared decision-making is the road away from this quagmire that we're in. I think there is a very clear role for shared decision-making. Treatments like surgical treatment of back pain, treatment of prostate cancer, where there's actually a lot of the patient's values that go into it — Do you value your life 10 years from now more than now? How much do you value the chance of incontinence or impotence or whatever? Those are very important things to have shared decision-making.
There are a lot of decisions, though, that I think I face as a physician, where the patient looks at me and says, 'Doc, you're the expert. I really want to know what you think. You know, I'm going to have to pay for this test. Is it worthwhile for me to get the test?'"