Is value based healthcare devaluing care?

There’s a lot to say for high value care. High value care is healthcare that generates a large amount of benefit for patients and the community compared to the resources invested. But there are also concerns.

Value based healthcare links outcomes with costs: ‘Value’ is derived from measuring health outcomes against the cost of delivering these outcomes. Although it makes sense to fund care that gives us the greatest health benefits, some argue that ‘value’ is more than outcomes.

Dr Jan Kremer is a Dutch Professor in patient-centred innovation and has a passion for patient-focused quality and innovation. In a recent blog post he questioned value based healthcare, stating that value has a different meaning to different people – ranging from efficiency to solidarity, equity and quality of life.

The right things

In healthcare, he said, it is not just about doing things right, but also about doing the right things. The former can be measured, the latter is about decision-making which can’t always be quantified. After all, we can achieve the desired outcomes by doing the wrong thing.

Indeed, a focus on outcomes only tells part of the story. Care may have value for people even when the outcomes are not good.

It is impossible to capture the complexity of healthcare through linear mechanical quality systems, like measuring isolated single-disease parameters. As Goodhart’s law says: ‘When a measure becomes a target, it ceases to be a good measure’.

Models that focus on outcomes often result in only modest improvements, usually not long-lasting and sometimes reducing quality of care for health conditions that are not targeted.

These models can negatively affect the patient-doctor relationship and take away the passion and enthusiasm of care providers.

Learning together

Everyone wants value in healthcare. Professor Kremer said we must be careful with anglo-saxon models that measure everything. But there are alternatives.

In the Netherlands, learning together based on shared values, and measuring less, has resulted in important successes. According to Professor Kremer outcome data has been helpful in the development of Dutch high value care models, but it never controlled the process.

Outcome payments and performance…

“G’day doc. I’m a little embarrassed to bring this up but…”

“No worries, you know you can be honest here. Let’s check your blood pressure first. It was a bit high last time.”

“Oh… ok. Not dangerously high I hope?”

“Well it was just above the benchmark, which is concerning. As you know I don’t get paid if I don’t look after your pressure. Let’s see… 140 over 90. Uh oh. I’m afraid we have to bump up your medications.”

“But doc, could it be stress? I wanted to tell you that…”

“Stress, stress… That’s all well and good but Medicare doesn’t care what the cause is. If it’s too high I miss out. And if I miss out you miss out, you know that don’t you? We also have to talk about your weight target. As I’ve told you before, if you don’t lose those extra pounds our practice cannot afford to look after you any longer.”

“Are you listening to me? John and I broke up last night. I’m a mess!”

“I’m sorry to say that there’s no incentive payment for counselling anymore. Please do me a favour and book in for your pap smear on the way out. Last time you were late and we missed the deadline for our quarterly Medicare bonuses. We don’t want that to happen again do we?”