Blog | Wednesday, February 17, 2016

The Value Tension


I spent this past weekend discussing internal medicine's future with colleagues. We spent our time forecasting, predicting and prioritizing. During those discussions the concept of the value tension evolved.

So why is the definition of value so important to internal medicine (and all other medical fields). The MACRA website says, “The MACRA will help us to move more quickly toward our goal of paying for value and better care. It also makes it easier for more health care providers to successfully take part in our quality programs …”

One might assume that value is easy to define. Congress must believe that we can measure value. But many physicians believe that value has different meanings to various stakeholders. Insurance companies (and we should include CMS here) adopt performance measurement as their definition of value. Yesterday's post reflects on the folly of that definition.

Patients do not have one definition. Patients are not homogeneous, rather their desires vary rather widely. Here are some criteria that I have heard from friends:
1. Accessibility
2. Visible evidence of caring (looking at the patient, appropriate touching, listening carefully)
3. Shared decision making
4. Making a correct diagnosis
5. After a correct diagnosis, knowing the most current treatment approaches
6. Clear explanations

Physicians also view value in various ways. Most internists want sufficient time to address all the patient's needs. We want to make correct diagnoses. We want to provide appropriate treatment for the patient who has the disease.

“The good physician treats the disease; the great physician treats the patient who has the disease.”

—William Osler

How do we reconcile these differing viewpoints of value? At least one dictionary has this definition: “relative worth, utility, or importance”.

So if the goal is to pay for value, we need an important thought experiment. Will focusing on one definition have a negative value impact for other definitions? The word value seems straightforward, but it describes a very complex process. Value has multiple dimensions. If we focus on some, but not all the dimensions are we really providing value. Rather are we describing a partial value.

No surprise here—patients say they are usually less satisfied with their doctor's care when computers were used during appointments, according to a recent JAMA Internal Medicine study.

Semantics are not just intellectual games. How we define value really matters. The first step is recognizing and accepting the concept of Value Tension.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.