Value in healthcare, a Welsh take
By Dr Sally Lewis, National Clinical Lead for Value-Based and Prudent Healthcare and Honorary Professor, Swansea University Medical School
Do we all have a shared understanding of what we mean by value in healthcare, not only across the nations, but also from hospital to hospital, doctor to doctor? I have a strong suspicion that the idea of ‘value’ simply generates ideas of ‘cutting costs’, but it is much more than that. We make value judgments in our lives on a daily basis. For example, if I buy the cheapest brand of baked beans at the supermarket but they are unpalatable, I am unlikely to eat them. That is a poor outcome and therefore, of little value to me. Equally, the most expensive brand may not be much tastier than the mid-range brand and therefore not worth the extra pennies, so also of little value. What information is available to me to help me make the best and most valuable choice?
Professor Michael Porter at Harvard Business School defines value as a function of outcomes and costs. It follows that in order to achieve high value we must deliver the best possible outcomes in the most efficient way, outcomes which matter from the perspective of the individual receiving healthcare and not provider process measures or targets. Consider the baked beans again. My perspective on the outcome of my purchase (which beans were palatable and which were too expensive for me based on the quality of the product), determined their value.
However, Professor Porter’s value theory is based upon a health system where the drive for a hospital to improve outcomes is to increase market share by offering the best service. This is not really relevant to population health and does not translate well to publicly-funded systems such as the NHS. But, before we throw the baby out with the bathwater, outcomes do matter. Professor Sir Muir Gray describes ‘personal value’ and ‘allocative value’, encouraging us to focus on shared decision making, individual preferences for care and ensuring that resources are allocated for maximum impact.
Empowering clinical decision makers to influence how resource can be allocated for highest value is of paramount importance if we are to create enthusiasm for reducing unwarranted variation and lower value interventions. As doctors, we should be the stewards of NHS resource from student to retirement. We must be mindful of opportunity costs, or there may be less to go around for the very things that make life worth living and promote health and wellbeing for future generations.
The problem in our current system is that we are not set up to assess value. Much that is low value from a patient’s perspective is invisible to us, possibly because we have not been able to track real patient outcomes or goals, including functional outcomes, in a systematic way. This is often because of a lack of supporting informatics and, frankly, because it would be a big change to the way we work. I believe that measuring patient outcomes at scale is something that we should be devoting more of our attention to. I also think that how we use this information to support patient care is more than analysing a big dataset and attempting to generate cost effectiveness scores. What matters to the patient needs to also matter to the physician.
However, if we were to support this change to the way we work, supported by appropriate IT, what changes would we see in both clinical outcomes, and patient experience of care? Consider my examples below, where I have outlined several ways in which value considerations in the provision of care in both chronic disease and episodic care.
Utility in chronic disease
i) prioritisation of issues
Patients tell us that they are able to prioritise and rank the most important issues to be addressed from their perspective. This is a useful aide memoire for conversation between physician and patient and improves the patient experience by facilitating a two way exchange of knowledge, expectations and goals.
ii) shared decision making
Tracking PROM data can also be useful as a more objective assessment of the impact of an intervention such as a new medication.
As data accumulates we will have the ability to utilise ‘real world’ outcome data in reflecting back to patients information better tailored to their own context.
iii) support new models of care
Outcome measures (combined with the correct IT functionality) can form an important part of developing new approaches to more flexible models of care through enhancing communication with our patients.
iv) triggers for key decision points
Longitudinal tracking of outcome data reveals trajectories of disease progression over time and can therefore act as a trigger or prompt for key clinical decisions such as when to discuss anticipatory care planning.
v) needs assessment
Aggregated data allows for the identification of population needs. The characterisation and quantification of those unmet needs aids service planning and, crucially, the allocation of resource taking a system-wide view. We can then tailor services more properly to need.
Utility in episodic care
Outcome data can also inform shared decision making in preference-sensitive clinical scenarios, for example where an invasive intervention may be undertaken for symptom control but there may be significant risk/benefit trade-offs.
PROMS data is already in use to look at clinical variation and quality improvement but aggregated data of this sort does come with a health warning – even when adequately risk-adjusted it does not tell us about patient preferences or goals. Scores are not the be all and end all. Assessing value across a surgical pathway also assumes that this was ‘the right thing to do’, for example, that the same outcome could not have been achieved through different management approaches. High quality does not necessarily always equate to high value and ideally we should be tracking outcomes in patients who were conservatively managed as well as those who had a procedure.
Finally, I have written about Voltaire before in the context of value-based healthcare. I raise these points again now to to challenge us as physicians:
Doctors pour drugs of which they know little to cure diseases of which they know less into patients of whom they know nothing
This quote reminds us to be careful about what we think we know and suggests we must take much more care to find out what our patients really want and are seeking to achieve. We have to remember that even the highest quality evidence on which we base our treatment decisions is still to an extent dependent on an ideal population with many exclusions. Perhaps longitudinal patient outcome data tracking will give us the information that we need to move from ‘ideal’ to ‘real’, and convince Voltaire that we know considerably more than nothing about our patients.
The art of medicine consists in amusing the patient while nature cures the disease.
This second quote reminds us of the need to be cautious about hurtling along clinical pathways, treating guidelines as rules, failing to contextualise and therefore risking over-treatment.
For me value-based healthcare is about reclaiming the art of medicine in the pursuit of good outcomes, with ‘good’ defined as an efficient use of resources for a mutually shared positive experience between patient and physician, and for the system more broadly (personal and allocative value).
What is it about for you?