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?'”
