Expressing value in health care

Value-based health care (VBHC) is discussed frequently in health care plans and by the federal government, health care economists, and clinicians. A large share of payors are focused on how to tie value to payment; yet, the definition of value and how to assess it seems to be widely variable. How is value defined, measured, and rewarded in the health care industry? Value to whom? How do clinicians measure the value they provide to their patients? What do patients think when various stakeholders refer to VBHC? Do patients more often rely on recommendations from friends, family, or their referring clinician when deciding where to go for care? What information do patients and clinicians use during the shared decision-making process to determine what the patient values? How can measures of value be assessed to drive quality improvement cycles and help in achieving patient goals of care?

This article highlights the state of informing patients about VBHC and the need for centering measurement on the unifying goal of medicine to deliver value to the patient. The authors share mock-ups that clinicians, patients, and other stakeholders may use as a springboard to express and assess meaningful value, and to frame value-based care around the goal of meeting the needs of the patient given their health care condition. These needs include aspects of quality outcomes and safe care, as well as the total price of care. Most importantly, this framework emphasizes that meeting the patient’s needs, including individual goals and expectations, is central to determining value.

This article describes how to design a dashboard for expressing the elements of value in a manner useful to patients and their care team. If health care business models are to transition to a value-based system for surgical care, it is important to understand value and transparently express value to patients and to clinicians.

What is value?

The Institute of Medicine (now known as the National Academy of Medicine) brought the concept of quality to health care in 2000 with To Err Is Human: Building a Safer Health System.¹ This publication led the health care industry to develop measures and call for incentives rooted in quality. Payors defined quality as avoidable harms, such as surgical site infection (SSI) and readmissions. But did this effort lead to better outcomes or was reducing the number of adverse events merely a proxy measure of safety? Did these measures assess whether patients’ surgical care would meet their expected goals for solving their problem or improving their quality of life?

In 2006, Michael Porter, MBA, PhD, and Elizabeth Teisberg, PhD, challenged the health care industry in their landmark publication, Redefining Health Care: Creating Value-Based Competition on Results.² Porter and Teisberg drew attention to the value and outcomes of care. They defined value as centered on the needs and goals of the patient and asserted that achieving better outcomes that matter to patients in a cost-effective manner must be the overarching goal of the health care industry. They emphasized the need for team-driven care based on conditions organized by integrated practice units (IPUs). Under this model, modern-day surgical teams care for patients across all the phases of surgical care, from preoperative evaluation to post-discharge, and collaborate with other clinicians to meet the full needs of patients.

Importantly, Porter and Teisberg tied outcomes more directly to the patient’s goals and expectations. If a patient with preoperative right upper quadrant (RUQ) pain undergoes a cholecystectomy, did the operation resolve their RUQ pain as the patient expected? Tracking patient goals and outcomes started the dialogue that suggests it is not enough to avoid harm and complications. Value in surgical care means the surgical team must ensure more than just avoiding adverse events—a concept that originated with the “End Result Idea” of Ernest Codman, MD, FACS.³

Principles of value measurement and expression

Value for whom?

A commonly raised question centers on who defines value. This can be seemingly a confusing question in an industry that involves patients; employers as purchasers; federal and state regulators; and third-party payors, such as commercial insurers, government funders, and so on. In the present fee-for-service system, different stakeholders have competing goals. The tendency is to define value based on volume, resulting in a zero-sum game; clinicians are rewarded for delivering more services, and payors try to limit spending, leaving the patient lost in the middle.

In contrast, value-based health care is about putting the patient at the center, with clinicians competing to produce the best outcomes for patients. Just like any other industry, health care exists to meet the needs of its customers—that is, patients. Patients define value. Value defined in those terms unites the industry as a whole. Patients and their families are focused on better outcomes at an affordable price. Government payors and employers ultimately want their citizens and employees healthy and back to work as quickly and financially sustainably as possible. Physicians and the clinical team are inherently motivated to treat disease and improve the lives of their patients.

Value is driven by the condition

Across nearly all other industries, highly personalized service models are created most successfully at companies that build around a customer-focused strategy that looks for groupings (or segments) of customers with the highest degree of overlapping needs and then develops a sustainable model around those needs. In specialty care, patients’ needs are driven largely by the condition for which they are seeking treatment. Value for patients is created by the care delivery process starting from the point of diagnosis through any interventions to recovery, rehabilitation, and monitoring of long-term outcomes. This care delivery value chain requires input from and coordination across many members of the integrated team, as well as collaboration with caregivers such as physical therapists, home health care aides, and rehabilitation providers.⁴ The patient’s condition dictates the team members required, the types of resources (facility, equipment, pharmaceuticals) needed, and the risks that should be mitigated. What is most meaningful for a patient with severe knee osteoarthritis is very different from what matters most in the care and outcomes for a patient with lung cancer. The International Consortium for Health Outcome Measurement (ICHOM) works globally with clinical experts and patient input to develop outcome measure sets that capture the key outcomes that matter to patients at the condition level.⁵

Value is a relationship, not an equation

Value is not meant to be a calculation; rather, value is a relationship, a way of comparing how clinicians meet the needs of patients in the numerator with the overall cost of care as a denominator. When comparing two clinicians with similar risk-adjusted outcomes, patients will search for the one who can provide care more conveniently and affordably.

The health care industry lacks the traditional trade-off between quality and price. In fact, if the long-run view of cost is considered, often the number one way to reduce cost for the patient overall is through better outcomes. The sooner patients regain their health and retain that health, the lower overall cost to the system. When we meet the health goals of patients and return them to as many of their daily activities as possible, other comorbidities and health concerns are less likely to arise. Furthermore, clinicians with track records of high-quality care are often lower in cost even in the short run. The attention to patient care, measurement, and process improvement that leads to quality care also leads to better efficiency, especially at higher volume centers. In surgery, we have seen an association between higher quality and lower cost in surgical care for certain procedures.⁶

Value for patients is multidimensional

The simplicity is tempting, but the goal of measuring value never should be to arrive at a single number. Patients are multidimensional in their needs and what is important and valuable to them. Value is multifaceted because patients are multifaceted.

Condition-level value creation is supported by activities and oversight across all levels of clinicians and health care facilities. We know that there are economies of scale and benefits to sharing resources and systems, and a culture of quality at both the domain level (such as trauma or cancer care) and the institutional level contributes to our ability to deliver value at the condition level. Therefore, outcome measurement focused on the patient should be supported by quality and safety metrics at multiple levels within the involved institutions.

The categories defining quality include verification (or structural and process) measures, safety measures, risk-adjusted clinical outcomes, patient experience, and patient-reported outcome measures (PROMs).⁷ The verification measures as a set represent the infrastructure, resources, and processes needed to deliver optimal care with high reliability. When a care delivery system is verified by a third party, the public is assured that complex care models and clinical pathways have the appropriate resources, that care is coordinated across the phases of surgical care, and that there is shared accountability. Patient experience will reflect whether patients felt they were treated respectfully, whether they felt their voice was heard and personal goals understood, and if they experienced a trusting relationship with the care team. Clinical outcome measures should be condition-specific using risk-adjusted data measured by clinically defined metrics of outcomes that matter to patients.

PROMs indicate whether the operation or intervention was successful based on why the patient sought care and whether the treatment was able to deliver results on the initial goals of care. PROMs may include such factors as whether the patient was able to regain function, if the treatment relieved their pain, if they were able to return to normal activities, and so on. PROMs also can be used for digital symptom monitoring, as they have been shown to be effective at improving symptom control, quality of life, survival for cancer patients and less frequent emergency department visits.^8,9 Dimensions that are critical for inclusion in the “numerator” of a value relationship will vary based on the condition. The numerator for colon cancer will be different from what is needed for breast cancer, a knee replacement, mental health conditions, and so on.

Value expression

But how do we pull these dimensions together in a way that is meaningful to patients so they can apply their own judgment to their needs? To do this, patients must be educated about their choices, become the center of the shared decision-making process, and feel respected and part of a trusted relationship with the care team in order to determine their goals of care and what dimensions they value most. Then, the expression of value to patients must be described in terms that are meaningful to them and mapped to dimensions of their condition that support that goal.

Value should be expressed graphically for ease of interpretation. The graphics should visually convey the many complex dimensions of a condition and be easily understood by the intended audience. Patients and clinicians have grown accustomed to bar charts, which is one way to express the dimensions, but we offer some additional graphics that might help bridge the gap between patient goals and how the clinician assesses a condition so that the assessment aligns with that goal. To illustrate how to assess value based on the many dimensions that matter to the patient, we offer a hypothetical patient as an example.

Value expression: A hypothetical breast cancer patient

For illustrative purposes, we consider what value expression might look like for a breast cancer patient. However, the metrics and tools used to assess value for breast cancer and other conditions will need to be tested and validated before implementation.

A 67-year-old female with a suspicious mass with calcification on breast imaging (mammogram) is being referred for diagnostic and subsequent treatment. She has some underlying medical conditions and is selecting her site for further care based on her primary care physician’s recommendations and referrals from family and friends. To determine what matters to a patient, the clinician would share a breast cancer diagram (like the one shown in Figure 1) to help facilitate the establishment of goals for the patient’s condition and foster the shared decision-making process. What is most important to the patient? To prolong life, share in decision-making, retain some sense of normal living, optimize functional and psychosocial status, and so forth, are all potential goals of care.

FIGURE 1. PATIENT GOALS OF CARE IN BREAST CANCER

A patient’s assessment of what is valuable begins simply, and as care increases in complexity the patient’s expectations evolve. A final patient assessment of value is multidimensional and complex, stemming from overall health and the conditions that alter health status. Factors such as age, cultural background, race, ethnicity, past experience with the health care system, access to care and affordability, to name a few, are all part of a patient’s calculus when applying judgments and setting personal health care goals. Patients build their numerator of value based on the outcomes of care that matter to them.

Domains of value expression

This patient leads a full, active life with three grandchildren. She still travels to visit family and friends. While her everyday activities are important, she is willing to take on more intensive treatment and deal with side effects if it will prolong her life and let her continue to do the things she loves. After initial diagnostic procedures and a confirmed diagnosis of an invasive malignancy, discussions about possible treatment options and goals of care become more narrowly focused.

The patient’s expectations and hopes evolve into further detail now that she is more informed about her condition, as illustrated in Figure 2. Based on her past experiences, she re-emphasizes the importance of having agency over the decisions about her care and that she have a trusted, inclusive relationship with her care team. Understanding the various treatments also will help her to follow instructions for therapies. As she thinks about returning to normal, she learns more about the impact her condition and treatment may have on everyday life. She wants to understand how her pain will be managed as a result of surgery and if she should expect to feel anxious and depressed as a result of treatment. One likely treatment plan includes a double mastectomy, and, therefore, her care team discusses satisfaction with her body image and sexual health, including whether she wants breast reconstruction. She explains that she does not want to undergo any procedures such as reconstruction that may present additional complications and prevent her from getting back to her life. She is at peace with losing both breasts—she is more focused on becoming cancer-free.

FIGURE 2. EVOLUTION OF PATIENT GOALS

The breast cancer outcome domains in Figure 2, adapted from the ICHOM Standard Sets measure framework, expand on initial goals of care and show outcomes in various domains that matter to the patient. The figure can be used internally by the care team to help them deliver on those goals and externally with the patient to facilitate a more in-depth discussion throughout the patient’s care.

Quantifying and comparing multidimensional patient value

As the surgeon and care team better understand the patient’s goals and values, her definitive expectations are reflected in her patient-reported outcomes and also are represented by the clinical objective measures related to her overall care. One way to visualize the various dimensions (structural and process measures, risk-adjusted clinical outcomes, patient experience, and PROMs) is a radar plot.¹⁰ The patient’s surgical team can use the plot for internal quality improvement and to choose the appropriate care pathway in order to map to her values and goals. Then, value can be assessed based on all the dimensions of the radar plot coming together across the course of her care, including whether her personal goals were met.

Figure 3 illustrates a radar plot for the patient’s breast cancer to graphically summate the various dimensions that both the patient and their care team could use to apply judgment. What is included on the radar plot will be chosen by the patient’s multidisciplinary team based on what matters to the patient alongside what the clinical team must track to deliver on patient goals and ensure patient safety. Appendix 1 considers dimensions to include on a radar plot, using breast cancer as the hypothetical example. Applying judgment requires the use of metrics to assess how well the care team did on delivering value to the patient. The plot is scaled from 0 to 10, where 0 is the worst performance, and 10 is the best—for all axes, the further from the center, the better. In Figure 3, Hospital A is compared against the national average for breast cancer, allowing for cancer teams to see how they compare with their peers. The radar plot indicates that Hospital A is above the national average for the following: disease-free survival in breast cancer, meeting patients’ body image goals, patients’ emotional well-being, creating an environment of trust and inclusivity, and involving patients in the decisions of their care. Hospital A is at the national average for SSI and for patients to resume activities of daily living, and just below the national average for relieving pain and minimizing fatigue. Hospital A delivers this care at a more affordable price than the national average.

FIGURE 3. DIMENSIONS USED TO APPLY JUDGMENT

Radar plot discussion

Integrates patient-reported and clinically reported measures

In the breast cancer example, the radar plot is specifically designed for the care team’s use to track to the what the patient values. It maps to the initial discussion with the patient about goals of care (see Figure 1). The radar plot expands on the domains in Figure 2 by representing metrics that the care team uses to deliver on the patient’s goals.

It is worth noting that the value assessment relies heavily on PROMs appropriate for the condition, because these metrics can be used to recenter the unifying goal for value to the patient. For example, clinicians have found the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire–Breast Cancer Specific Questionnaire (EORTC QLQ-BR23) and the BREAST-Q–Satisfaction with Breasts tools helpful for tracking a patient’s body image and satisfaction with breast(s). Another example clinicians found helpful to track physical, emotional, cognitive and social functioning, ability to work, and overall well-being is the EORTC Quality of Life Questionnaire–Core Questionnaire (EORTC QLQ-C30). ICHOM is a source to consider for identifying PROs and other metrics. ICHOM has created standard measurement sets for 39 conditions by convening physicians, measure experts, and patients.¹¹

The radar plot also tracks dimensions that the patient would not necessarily be thinking about but that are critical for the care team to track to deliver optimal care, such as conformance quality and reliability, including preventable harms. The dimensions in the radar plot and outlined in Table 1 are examples of domains and metrics that we might want to validate as instruments but they would need to be tested before implementation. Examples of the various dimensions are described in Table 1.

Ultimately, each patient has a unique set of goals, priorities, outcomes, and elements they most care about. Patients value health care differently when they apply personal judgment based on their individual circumstances and goals. By measuring, expressing, and visually portraying the multidimensional nature of outcomes, patients can discuss the considerations with clinicians and place their own personal judgment on top of the radar plot. Patients assign weights to the different dimensions based on what is most important to them.

Reflects team-based care

The visual representation of the radar plot underscores the team-based nature of medical care, illustrating the need for coordinated care with shared accountability. The multidimensional nature of the plot makes it clear that one provider could not be responsible for delivering all of the various outcomes. Many dimensions are led by different teams of clinicians and the only way to deliver overall high-quality care to the patient is for every provider to perform well both within their areas of expertise and with inter-team collaboration. To support assessment, improvement and reward for individual and team-based results must be aligned with a central goal.

Value expression used by different stakeholders

Although the radar plot in this example is for breast cancer care teams, any stakeholder can use it to assess value. With support from the care team, patients can use radar plots to inform shared decision-making or to choose a clinical team. Departments of surgery might use the data to incentivize improvement with financial levers or special recognition, and payors might use a radar plot to make purchasing decisions or within incentive payment programs. Depending on the complexity of a condition, more than one radar plot might be useful in expressing value. In this example, the radar plot is limited to 10 dimensions for ease of interpretation. The dimensions include standard comparisons for a condition across multiple sites that can be customized based on the appropriate level of information for value assessment and/or based on information available for a condition. More research is needed for most conditions to determine which indicators are most important to patients.

Radar plots are not commonly used and will take time for clinicians and patients to learn to use in their decision-making. It is important to acknowledge that most patients will not have been exposed to the complex clinical sequela of their condition expressed with measures on a graphic. Patients will need to partner with a clinician acting as a “health coach” to navigate the best path forward based on the severity of their condition, their preferences, and their goals. The calculus (or relative weighting of each outcome dimension) will look different for each patient, and patients, along with their health coach and caregivers, will discuss different outcomes as they decide what is valuable to them.

Value expression for equitable care

As the U.S. transitions toward VBHC, value assessment plays a critical role in the system’s ability to transform into a more accessible, affordable, transparent, and equitable system. VBHC is designed to achieve outcomes that matter to the patient at a price that the patient and the system overall can afford. The impact this has on access—by holding health care institutions accountable to price—will force them to look internally at their own costs, and that will drive affordability with increased transparency. Looking across the delivery systems and measuring outcomes brings to light disparities in care, which is the first step in addressing inequities. As the coronavirus 2019 pandemic has demonstrated, there is a critical need to better measure inherent disparities in order to bring attention and investment to under-resourced areas and populations, and then change the payment system to be accountable for the results of every individual. VBHC is an opportunity to improve communication with a more diverse set of patients and to build trust within communities that have previously been excluded. Developing and implementing patient-reported metrics of inclusion in the care process is one important step in addressing systemic bias.

Conclusion

As health care moves deeper into VBHC, it is important to meaningfully portray value for patients and care teams. The current payment incentive programs are just scratching the surface of providing the information patients need to assess value and therefore have a limited effect in driving more continuous quality improvement. The strategies outlined in this article represent initial thoughts about ways to express value in a more meaningful manner to the different types of stakeholders. More work remains to identify what is meaningful to the end-users and to help recognize the barriers we face in a large-scale implementation of delivering value to patients in the various care models and in payment models.

Adapted from aspects of the ICHOM Breast Cancer Standard Set. Available at: https://connect.ichom.org/standard-sets/breast-cancer/. Accessed May 19, 2021.

References

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