Consider this scenario: Over the past six months, you’ve developed persistent headaches. You finally see your doctor, and in order to diagnose the problem, she offers you a choice: For $750, you could have a CT scan that will evaluate 80 percent of the things that could be causing your headaches. Or, if you’re willing to pay $2,500, you could have an MRI scan, which would evaluate 99 percent of the possible causes.

Is that modest increase in accuracy ­­­worth an extra $1,750?

Your answer might differ from what your neighbor would choose, what your doctor would recommend or what your employer is willing to pay for as part of your medical benefits.

As a recent University of Utah Health survey revealed, individuals and different stakeholders in America’s health care system have drastically different interpretations of what “value” means.

“We need to have a much better understanding of how those who receive, provide and pay for health care understand value and prioritize its component parts — quality, service and cost,” says Robert Pendleton, MD, chief medical quality officer for University of Utah Health. “The things that Medicare and other payers hold me accountable for under the auspices of value, for example, are far removed from what I think patients actually care about when they think about value.”

To that end, University of Utah Health’s Value in Health Care Survey examined how three distinct stakeholder groups perceive not only the health care experience, but also who is responsible for improving it. Participants, comprising 5,031 patients, 687 physicians and 538 employers, were given a list of more than a dozen “value statements” and asked to select the five that meant the most to them.

A surprising disconnect

Although their responses covered a broad range, patients tended to focus on the bottom line. Their most commonly selected value statement was “My out-of-pocket cost is affordable” (45 percent).

Employers also prioritized affordability, with “The cost to the employee is affordable” (59 percent) their highest-rated value statement, followed by “The cost to the company is affordable” (57 percent).

Among physicians, the most commonly selected value statements prioritized the quality of care over its cost. “I know and care about the patient” (55 percent) was the top response, followed closely by “I order the appropriate exams, labs, and imaging,” (55 percent) and “The patient’s health improves or stabilizes” (50 percent).

Patients appeared to place far less importance on good clinical outcomes than physicians did. In fact, less than a third of patients selected “My health improves” as one of the top five things they value most in health care. “It surprised me — and as a doctor disheartened me — that more patients didn’t perceive health outcomes as a top priority,” Pendleton says.

Follow-up interviews suggested several possible explanations for this surprising result. Some healthy patients said they didn’t need their health to improve; some patients with chronic conditions said they didn’t expect their health to improve.

Whatever the reason, Pendleton notes that it’s vital for physicians to recognize that health outcomes are not the only thing patients value. Affordable, convenient, friendly and accessible care is sometimes equally important. “Until doctors and health systems fully embrace that reality,” he says, “it’s going to be hard to move the conversation forward.”

Re-evaluating value

Some physicians are uncomfortable taking a view of patient care that’s as nakedly transactional as the choice of diagnoses (and costs) offered in the hypothetical headache scenario above. “They don’t like the analogy of shopping for a car, where you acknowledge there are tradeoffs in terms of how much more you’re willing to pay for that one little extra safety feature, or leather seats versus standard seats,” Pendleton explains.

Uncomfortable or not, there’s some truth in that comparison. “In most areas of our lives, we understand these tradeoffs,” Pendleton says. “But in health care, doctors are ill-equipped to have meaningful conversations with patients about those tradeoffs.”

Nevertheless, Pendleton is hopeful that the survey results “are starting to send signals that we can have a discussion around those tradeoffs. Otherwise it’s going to be hard to have a unified vision of how we make the best decisions for individual patients.”

The goal of the Value in Health Care Survey was to provide a framework for a more productive discussion of how to achieve good value. Ultimately, it may come down to recognizing that semantics could play as big a role in improving America’s health care as medicine and economics. Reaching consensus on a definition of terms is a critical first step.

“Until we have a shared vision of what we’re trying to achieve, it’s going to be hard to move forward in a meaningful way,” Pendleton says. “If everyone is pulling in a different direction, then eventually we’ll get to a point where we have a very mediocre health care system where ‘improvement’ amounts to nothing more than cutting costs. We aspire to do better than that.”

 

If you’re interested in learning more about the survey results, please feel free to contact Seth Bracken at seth.bracken@hsc.utah.edu.

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