What is “Value” in Health Care?

April 8, 2013

Lisa Rosenbaum wrote a terrific piece in the March 7 issue of the New England Journal of Medicine. Her article is a powerful reminder that views of medical appropriateness—what is “right” in health care—can be very different for physicians, patients, and analysts. She highlights the challenges inherent in a system of incentives that reward “value” without taking into account these differing views, and speaks to something often missing in today’s health care: real communication between physicians and patients.

We live in a culture that over-values “doing things” and under-values doing nothing. Many Americans believe that unless they get tests, drugs, or other interventions when they visit the doctor, they are not getting good medical care.

Physicians often reinforce this viewpoint. I’ve been amazed at the number of times physicians themselves speak to their discomfort at not doing a test, concerned they may be viewed as withholding something from patients rather than simply taking a more prudent approach to health care.

While we often talk about defensive medicine, and how fear of litigation may promote the use of too many medical services, I think an even more pervasive issue is physicians’ concern about being perceived as rationing health care.

In his very fine book comparing international health systems, T.R. Reid discusses how he traveled the world to understand differences in health care systems, using his own shoulder problems for the comparison. Not surprisingly, his American physician was quick to offer a major surgical intervention while those in other countries were more cautious in approach, expressing more skepticism about the value of surgery.

At core, however, unless physicians and patients are on the same page about which medical interventions make the most sense, there will be conflict about perceptions of value. And as long as patients think doing more is better—whether diagnostically, medically, or surgically—payment approaches using incentives to affect physician behavior are not likely to work. In the end, physicians care more about their patients’ reactions than incentives from health plans.

Rosenbaum hints at a solution in an anecdote about a patient’s fear of heart disease. The patient wants a pill or some other intervention to fix his problem. But in the end, the problem needed to be addressed with behavioral changes, like diet and exercise. His physicians perceived him as being resistant to change, but in fact, he responded very positively when a senior doctor sat down and talked him through his issues in detail.

Here’s the challenge: that senior physician spent 75 minutes talking—just talking—with the patient and his wife. But in health care today, we generally don’t reimburse well for 75 minutes of talking. We do, however, reimburse handsomely for the procedures that physician was discouraging his patient from having.

Until we do a better job of aligning reimbursement systems so patients and doctors can be on the same page, all the incentives in the world won’t get us to a true improvement in the value of health care.