Defining “Value” in Value-Based Medicine: A Work in Progress

Achieving 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. health-care 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, 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 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 out-of-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. “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 standardization of treatment, may or may not be embraced.”

Complicating the idea of value further are the degrees of variance among physicians and patients themselves. “Individual people will disagree on how to prioritize things like length of life versus quality of life,” Dr. LeBlanc said. “While one person may want to take any measure to extend his or her life as long as possible, others may not want to put themselves through certain treatments or procedures if they only have three months left to live.”

The Complications of Hematology

There are unique challenges within the field of hematology that make measuring value more difficult. In other specialties, measuring patient outcomes can be more straightforward. For example, in cardiology, value and outcomes can be measured by patients maintaining blood pressure or cholesterol goals, or by reducing the rate of hospital readmission for patients with heart failure.

According to Dr. Bolwell, hematology is one of the most intellectually complex specialties in medicine, for treating both malignant and non-malignant disorders.

“Malignant hematology alone includes diseases, like acute leukemias, that are treated with fairly dramatic interventions, like bone marrow transplantation that requires intensive inpatient hospitalization and tremendous utilization of health-care resources,” Dr. Bolwell said.

The area of non-malignant hematology includes a group of uncommon – and clinically intensive – diseases. Thrombotic thrombocytopenia purpura, for example, is associated with significant resource utilization and long-term toxicities and related illnesses.

“Because these diseases are not particularly common, defining value and quality metrics to measure is not as straightforward as in other subspecialities,” Dr. Bolwell said.

In addition, hematology – especially in the area of hematologic malignancies – has been at the forefront of genetic personalized medicine for a few decades, Dr. LeBlanc added. “The first truly targeted treatment was for chronic myeloid leukemia,” he said. “Increasingly, when hematologists are taking care of patients, we are sending them for tests to look at genes or chromosomes, while also working to develop drugs to target those things. That kind of innovation is costly.”

A Special Symposium on Quality at the 2014 ASH Annual Meeting discussed the rising cost of medical care, including the rapid increase in new drugs becoming available every year, and their associated costs.  “Many diseases in hematology are rare diseases, and there is a big cost associated with developing treatment with fewer patients to deliver those drugs to,” Dr. LeBlanc said.

“Companies need to make a return on their investment so they are able to continue to develop helpful therapies. We need to start thinking about the appropriate balance between innovation and profit and ask ourselves, ‘When is it too much?’”

More Value, Less Health Care?

As the system shifts to a more value-based model, it may be intuitive to think that better value equals fewer interactions with the health-care system. However, Drs. LeBlanc and Bolwell believe that higher quality health care will require the opposite.

“High-value care requires more encounters with the health-care system and, certainly, more meaningful encounters,” Dr. LeBlanc said. These interactions will start in the primary-care setting with patients seeing their primary-care provider more often to get preventive health-care services – something that the Patient Protection and Affordable Care Act aims to increase by requiring most health plans to cover preventive services like shots and screening tests.

Dr. Bolwell agreed with this viewpoint, adding that improved value will mean more interactions with the health-care system, but not all of those interactions will necessarily be with physicians. Other health-care providers, such as nurses, medical assistants, social workers, or pharmacists, should play a role as well.

“In newer team-based approaches, if a patient skips an appointment with one member of the care team, other members will call the patient to find out why the appointment was missed and get the patient rescheduled quickly,” Dr. Bolwell said. “That is one of the most valuable parts of the new health-care world.”

The Bottom Line? Embrace Change.

The shift toward a value-based system is already well in progress and it is important that hematologists, and all physicians, embrace this change – or at least accept it. According to Dr. LeBlanc, one of the key components of injecting more value into the health-care system is to improve the way that physicians and patients communicate and increase the use of shared decision-making.

“We have to improve the quality and nature of our interactions,” Dr. LeBlanc said. “In the case of cancer, for example, we know that a large proportion of patients with incurable solid tumors misunderstand the goal of cancer treatment.”

Specifically, a study published in 2012 showed that 69 percent of patients with lung cancer and 81 percent of patients with colorectal cancer enrolled in the study did not understand that their treatment was not likely to cure their disease.⁵

“If our patients better understand the goals of treatment they might make different choices or reorder their priorities,” he said.

Improving communication, addressing psychosocial distress and anxiety, and improving the patient experience are all components of value in the field of hematology. “All of these things represent an opportunity for us to take better care of our patients,” Dr. Bolwell said.

“Hematology leadership have to move beyond the traditional job definitions of academia and embrace our responsibility to define value in the field of hematology for the NIH, for the payers, and other providers,” he said. “Once academic leadership in hematology embraces the concept of value, it can start to generate results.” — By Leah Lawrence 

References

1. National Center for Health Statistics. Health, United States, 2013: With Special Feature on Prescription Drugs. Hyattsville, MD; 2014.
2. National Health Expenditure Projections 2013-2023. Accessed December 19, 2014, from www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trendsand-Reports/NationalHealthExpendData/Downloads/Proj2013.pdf.
3. Institutes of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: The National Academies Press, 2013.
4. Christina LaMontagne, NerdWallet Health. “NerdWallet Health finds Medical Bankruptcy accounts for majority of personal bankruptcies.” Accessed December 22, 2014 from www.nerdwallet.com/blog/health/2014/03/26/medical-bankruptcy/.
5. Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:1616-25.