The Explosion of Explorations of Value-Based Care
A PubMed search of the phrase “value of care” produces over 20,000 results from 2020 alone. That is more than five times the number of results from twenty years earlier, and over twice as many as just 10 years ago. The increase in the number of results for the phrase “value-based care” from 2010 to 2020 is over 1000%. Even the phrase “return on investment” has experienced significant increases in the literature over that time frame.
Obviously, these trends reflect changes in policy and reimbursement of care that attempt to incorporate aspects of quality and value. At some point, we felt like we had figured out how to measure quality well enough to link payment to quality performance and say that it was a “value-based” payment. (It’s not, by the way…it’s a quality-measure-performance-based payment, and the link to value depends on how closely those quality measures serve as surrogates for value as well as our definition for the subjective concept of value…but that’s another topic.) In the process of linking payment to quality measure performance, we realized that if we’re going to promote and incentivize “high value” care, we need to try to assess, quantify, and define (or explain) value.
For those seeking funding for research or quality improvement, this has specific implications for how to design projects and frame proposals. Whereas it used to be enough to demonstrate the improvement in clinical outcomes or functional knowledge, it is now also typical to have to show an increase in “value” for key stakeholders. Who those stakeholders are (whether they are patients, payers, or others), and their unique perspective regarding the improvement are essential considerations to properly discuss value.
The Struggle to Assess Value
The difficulty faced by many healthcare professionals in this new reality is a lack of knowledge or understanding of how best to assess value. In fact, one could argue that as an industry, health care struggles to know how best to assess value.
In a 2019 article, Brayan Seixas and colleagues report the results of a systematic review of the different approaches used to assess value in developed countries.[1] From the more than 1,100 references originally identified, the authors ultimately review 38 articles. They identify “22 distinct approaches to assess value of health care interventions,” with cost-effectiveness and/or cost-utility analyses being the most common. However, the usefulness of the techniques is not universal. The authors conclude that the most common method “has not been sufficient to meet the needs of decision-makers.”
That’s really what we’re talking about, isn’t it? How to make decisions: whether to fund an intervention or not; which durable medical equipment to buy; how to incorporate clinically proven processes in a way that is financially feasible. The notion that the most commonly used tools to assess value in our industry are not sufficient to make these decisions indicates that there is a breakdown in the most fundamental axioms of how we think about value.
We can do better, and we can think beyond the usual tools for value assessments and begin to think about value in a new way.
Implications for the Future
As we move forward with value-based care we will need to work out how best to assess and quantify value if we are to base our policies and reimbursement mechanisms on it. We lack a shared understanding of what is meant by “value;” the term is sometimes used to mean strictly financial return, but other times refers to an all-encompassing ideal that includes patient experiences and societal and social well-being. We need to move beyond the over-simplified and impractical definition of value of “quality per dollar spent,” to a more functional framework for how to think about value in different situations. Understanding the different components of value can help guide the decision-making process, which should adapt as the situation calls for it. That is, there is value inherent in quality of life, physical functioning, and emotional well-being, but there are also financial realities that require we assess feasibility and sustainability of whatever is being considered.
The organizations best positioned to establish the value of their intervention, process, product, or device in the future will be those who understand the larger context of the care delivery system, and can intelligently speak to all aspects of value. A full grasp of how to think about and approach value provides the most flexibility and opportunity for appropriately and comprehensively addressing value for any individual situation. As Seixas and colleagues say in their article, “…we do not expect that there is only one correct ‘value’ for any intervention, even for a specific condition, i.e., ‘value’ is contextual.”
Let’s strive to evolve as assessors of value, so that we can begin to say that the most common assessments done are sufficient to meet the needs of decision makers, motive the best policies, and incentivize the best possible care.
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- Seixas BV, Dionne F, Conte T, Mitton C. Assessing value in health care: using an interpretive classification system to understand existing practices based on a systematic review. BMC Health Services Research. 19;560(2019).