THE ENIGMA OF "VALUE" IN HEALTHCARE

Can We Truly Have "Value-Based Care" Without Defining "Value" in Healthcare?

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One of the ubiquitous phrases in today's healthcare economics conversation is "value-based care," a seemingly utopian model that promises to shift the focus from the volume of care provided to the quality of care delivered. In my conversations with colleagues, patients, caregivers, and healthcare executives one thing has become glaringly obvious. “Value” in healthcare means totally different things to different people and depends mostly on the point of view of the stakeholder involved.

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This therefore leads me to ask, if we can't adequately define “value” in healthcare as it relates to the collective, how can we possibly transition to “value-based care”? Who or what determines this "value"? Can this "value" truly be quantified?

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Those of you who work closely with me or have followed me over time know that I like clarity. Definitions matter because they set the stage for understanding concepts bereft of all ambiguity. From my vantage point, the current concept of “value” in healthcare is still nebulous at best. Is it about patient satisfaction? Longevity? Procedural success? Quality of life? Cost-effectiveness? Readmissions? Or is it the uncanny Houdini like ability to shift cost?

I’ve seen multiple permutation of these, and others, used over the past few years in failed attempts to quantify “value”. ?This is because without a clear, universally accepted definition of what “value” is in healthcare, we're navigating in the dark without a compass and unable to read the stars.

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From a provider’s perspective, our current system is riddled with challenges that makes measuring “value” a complex and near impossible task. From a fee-for-service model that incentivizes quantity over quality, to fragmented care that hampers coordination, and a profound lack of transparency that leaves patients in the dark about costs and quality - we're far from having a clear understanding of “value”.

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In the quest for "value-based care", it's important to recognize that healthcare providers often operate in conditions where many factors influencing “value”, in whichever form one wishes to measure it, are beyond our control. Holding providers solely accountable for “value” in such circumstances demonstrates the lack of systems thinking that permeates our healthcare administrative and bureaucratic infrastructures.

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Consider for example the social determinants of health, which include factors like housing, education, and access to healthy food. These factors significantly impact patient's health outcomes. Nonetheless, the system often pretends that these factors don’t exist. A provider may prescribe a healthy diet and regular exercise to a patient with diabetes. However, if that patient lives in a food desert where fresh produce is hard to procure, or in an unsafe neighborhood where outdoor exercise isn't feasible, the provider's ability to deliver “value” - in this case, improved health outcomes for the patient - is severely compromised.

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Similarly, providers often work within a fragmented healthcare system that has somehow invented every possible barrier to hamper rather than coordinate care. A primary care provider may develop a comprehensive care plan for a patient, but if specialists and other providers involved aren't communicating effectively, the patient's health outcomes may suffer. In this case, the primary care provider's ability to deliver “value” is hindered by systemic issues beyond their control.

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These examples illustrate why it's crucial to consider the broader context in which providers operate when transitioning to “value-based care”. While providers have a key role to play in delivering “value”, we cannot do it alone. Systemic changes are needed to address the multifaceted systemic inadequacies in which we dutifully attempt to deliver high value care.

I’m still perplexed as to how regulators were able to force Apple to switch from its propriety lightning charging connector to the standard USB-C in its latest generation of electronic products. This was done to allow customers to use one cable to charge all their devices regardless of the manufacturer or brand. However, that same regulatory urgency and clarity aren't present in the "value based care" discussion. It is somehow seen as acceptable that patients with disparate educational, social and tech proficiency backgrounds should navigate 2-5 different portals which do not communicate with each other in order to manage their health! Shouldn’t that basic ecosystem of interoperable communication be part of any “value based” discussion? Shouldn't interoperability of systems to manage one's health take precedence over the interoperability of charging one's phone?

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So, the question remains: Can we truly implement value-based care without first defining what “value” means in the context of healthcare delivery?

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The essential tenets of “value-based care” should not be just about changing payment models, as is the case in contemporary general healthcare economics discussions. ?Value based care should be about fundamentally rethinking what we value in healthcare.