The buzzword in health care circles these days is value. In fact, HHS recently announced its goals and timeline for shifting Medicare payments to value-based payments, sparking more conversation about what is value in health care. This is, of course, generally a good thing. There is broad consensus across patients, providers, business, health plans, and others that we should be getting better results for the $2.9 trillion we spend annually in this country on health-related goods and services.
In all of these discussions, though, I am regularly seeing a glaring hole in the conversation. We talk about ways to improve value in health care delivery, in the way we pay for care and in the way we conduct medical research and use it to improve practice. All too seldom, though, do we ask what patients – those who are ostensibly at the center of the health care system – think, feel and expect regarding the care they receive.
The absence of the patient in our thinking becomes a tangible issue when it shapes policymaking and the development of new health care payment and delivery structures. We’re seeing an evolution in the way patient care dollars are spent. Accountable care organizations and bundled payments are examples of new approaches designed to wring waste and unnecessary tests and procedures out of the system. The objective is to achieve greater cost-efficiency while improving quality, thus providing better value. That naturally begs the question, value to whom? The doctor? The insurance company? The patient?
Putting the patient at the center of this equation was the goal policy-makers had in mind when they created a Patient-Centered Outcomes Research Institute and called for patient-focused drug development. However, this change has not yet made its way into health care payment and delivery.
In measuring the effectiveness of value-based payment and delivery concepts, there is a great emphasis on costs. Are we spending less to treat a heart valve blockage than we did a year ago? Ensuring that quality is enhanced or at least isn’t compromised in the pursuit of lower costs is critical, but the patient’s perspective is often missing. That’s not to say there aren’t quality measures, but typically those measures are designed from a health care provider’s perspective. We measure structure: does the doctor use an electronic health record? We measure process: was a recommended test ordered? And, we measure clinical outcomes: were the test results within recommended limits? But, we seldom measure the ultimate results: does the patient feel better? Is the patient able to engage in activities that are important to her?
If we go to great lengths to determine whether dollars have been sufficiently saved and clinical standards met, but fail to incorporate into our analysis the fundamental question of whether the patient feels better or worse, then we’re going to have a great deal of difficulty creating an optimal health care system. We certainly will fall short of the patient-centered health care system supported by policymakers on both sides of the aisle.
A recent report by Avalere Health addressed this challenge compellingly. They wrote, “If ‘value” is not defined appropriately – they (new payment models) could place undue emphasis on cost-cutting and create new barriers for patients, providers and other health care stakeholders as they seek innovative, clinically-appropriate care. If reforms do not incorporate patient-centric attributes of value, they risk conflicting with the movement toward patient and consumer engagement in health care.”
Integrating these patient-reported outcomes into health care policy and practice is not simple. It means creating reporting systems that will enable doctors, nurses and other health care professionals to collect patient perspectives in a systemic way. It means creating feedback mechanisms for providers to respond to patient-reported outcomes through the way they provide treatment and care so that patients are supported to achieve optimal outcomes. It also means creating structures that will enable health care payers – both government and private insurers – to include the patient experience in the formulas used for determining physician and hospital reimbursements.
Incorporating the patient perspective will make our health care system a better one, and, after all, aren’t patients the reason the health care system exists in the first place?
Thorpe, Ph.D., is chairman of the Partnership to Fight Chronic Disease (PFCD) and a Robert W. Woodruff professor and chair of the Department of Health Policy & Management in the Rollins School of Public Health at Emory University, Atlanta, Georgia. He also co-directs the Emory Center on Health Outcomes and Quality. He was deputy assistant secretary for Health Policy in the U.S. Department of Health and Human Services from 1993 to 1995.