FEATURE
Defining “Value” in Value-Based Medicine:
A Work in Progress
A
chieving optimal patient outcomes is
still one of the most important aspects
of health care. In recent years, a new
goal – and one no less lofty – is permeating
the health-care world: value.
Value can be defined in a number of ways,
with the definition varying depending on
whether it is a patient, physician, or administrator providing that definition. It is most
commonly associated with economic value. As
the rate of health-care spending in the United
States has continued to increase, so has the importance of value. In 2014, the National Center
for Health Statistics estimated that U.S. healthcare spending increased to a total of about $2.7
trillion for 2011, equating to almost 18 percent
of the country’s gross domestic product.1 National health expenditures are expected to grow
an average of 6 percent annually between 2015
and 2023.2
Even more alarming, a 2012 report from
the Institute of Medicine estimated that about
30 percent of health spending in 2009 was
wasted on unnecessary services, excessive administrative costs, fraud, or other problems.3
“We know that resources are limited and
that we spend far more than any country on
health. However, what we get in return is often
worse than or the same as countries that spend
less,” said Thomas W. LeBlanc, MD, assistant professor of medicine in the division of
hematologic malignancies and cellular therapy
at Duke University Medical Center in Durham,
North Carolina. “Clearly, something is wrong.”
Theory Versus Practice
In the health-care world, the current definition of value is “patient outcomes divided by
cost.” The concept sounds simple in theory,
but implementing it in reality is far more
complicated.
Put simply, it is the idea that if you manage
to improve outcomes for the same amount of
money, or you have the same outcomes but
are able to improve outcomes for less money,
you generate more value, according to Brian
Bolwell, MD, chairman of Taussig Cancer
Institute at Cleveland Clinic in Ohio.
“A lot of value-based medicine is cost
avoidance – for example, reducing the number
of hospital readmissions through appropriate
outpatient medical management,” Dr. Bolwell
said. “The ongoing problem, though, is that
there are so many different ways to define quality and to measure economic impact.”
First off, the concept of patient outcomes
can include a myriad of factors based on which
perspective you take – the physician’s or the
patient’s. Quality of care, safety, access to care,
timeliness of care, and more all take different
forms for the patient and the provider.
At Cleveland Clinic, Dr. Bolwell said they
are beginning to try to measure value in unique
ways as they relate to cancer and hematologic
malignancies. A patient with newly diagnosed
cancer may undergo tracking that monitors
how long it takes to get initial treatment, how
long it takes to get an initial surgical procedure,
if the patient’s fear and anxiety are addressed,
and more.
“Measuring things and tracking them are
the only way to begin to improve things,” Dr.
Bolwell said. “If we can do that, we can improve
one aspect of value as we define it.”
Another important aspect of defining value
in hematology will be the sharing of data between institutions and research organizations,
agree that we should do everything we can to
help the most people.”
However, patients and physicians may
differ on the definition of “doing everything
possible,” Dr. Bolwell noted. Although patients
clearly desire the best possible outcomes they
can achieve, they are also concerned about
economic ramifications, or so-called “financial
toxicities,” especially with newer insurance
plans carrying increasing deductibles and outof-pocket costs.
In fact, an analysis of data taken from the
U.S. Census, Centers for Disease Control, the
federal court system, and the Commonwealth
Fund showed that costs from health care were
the top reason for personal bankruptcy filings
in 2013, with 1.7 million Americans living in
households that will declare bankruptcy from
medical bills.4
From the other perspective, Dr. LeBlanc
said physicians may often feel at odds with
the idea of value in everyday medical practice.
“ ecause hematologic malignancies are
B
not particularly common, defining value
and quality metrics is not as straightforward as in other subspecialities”
—BRIAN BOLWELL, MD
he said. Hematologists, and all researchers ,
must begin to determine how research fits into
a value-based system.
“Clinical research, as well as basic and
translational research, remains vital to the
field of hematology,” Dr. Bolwell said. “We
need to consider partnership with insurance
payers, pharmaceutical companies, and with
government organizations such as the National
Institutes of Health to conduct both basic and
clinical research in a way that generates rapid,
favorable outcomes within a realistic budgetary
framework.”
Differing Perspectives
“It may be easiest, initially, to think about value
from the standpoint of the entire health-care
system,” Dr. LeBlanc said. “We know there are
a finite number of resources and a lot of people
with health-related needs, and most people
“Physicians are very focused on the patient in
front of them,” he said. “Our job and passion is
to do everything we can to give them the best
care and outcomes, but we can feel squeezed
sometimes.”
For example, he said, in today’s world
patients are in the hospital for much shorter
periods of time than ever before, and there
are limited hospital beds for patients who may
be very sick. “It is more difficult to get into a
hospital now and physicians are struggling
to manage complicated cases from the clinic,
meaning we can’t always help people in the way
we want to,” Dr. LeBlanc explained.
Dr. Bolwell agreed, and added that, for physicians, value-based medicine is a new field and
represents a substantial change in thinking.
“Human beings are often concerned about
change and physicians are an independent
lot,” Dr. Bolwell said. “New concepts, such as
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ASH Clinical News
January 2015