The wide consensus that health care spending poses a threat to the nation’s fiscal solvency has led to the championing of “value” as a goal of health care reform efforts.
In a Medicine and Society article published this week the New England Journal of Medicine, “The Whole Ballgame — Overcoming the Blind Spots in Health Care Reform,” Rosenbaum writes that rather than facing the big-picture reality that spending less will mean sometimes having less, a more hopeful -- but misleading -- emphasis on pursuing high-value health care has emerged as the dominant paradigm. But, notes Rosenbaum, “Value in health care depends on who is looking, where they look, and what they expect to see.”
The emphasis on value effectively splits patients and physicians into separate groups. When the focus is on physicians, creating value means reducing overuse, increasing efficiency, and providing incentives to deliver evidence-based care. But when the focus is on patients, creating value means enhancing patients’ experience and paying attention to processes and outcomes that matter to them.
The problem, says Rosenbaum is that both concepts of value sound promising in isolation and, to their respective adherents, reinforce the illusion that each can improve health care. But when viewed together, contradictions can arise. For example, Rosenbaum cites patients who ask their physicians for batteries of tests to achieve peace of mind about an illness -- even if there is little or no evidence that doing so delivers better care or produces better results. A patient-centered approach would acknowledge the psychological benefit that patients derive from undergoing such tests; but a physician-centered approach would caution against administering costly tests that have little or no data to support their efficacy. Further complicating this dichotomy are studies showing that, for instance, patients who receive medical imaging, regardless of whether it is truly indicated, are generally more satisfied with their care.
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