- Email: [email protected]
Patients Should Define Value in Health Care: A Conceptual Framework
THE HAND SURGERY LANDSCAPE
Patients Should Define Value in Health Care: A Conceptual Framework Robin N. Kamal, MD,* Sarah E. Lindsay, BS,* Sara L. Eppler, MPH*
The main tenet of value-based health care is delivering high-quality care that is centered on the patient, improving health, and minimizing cost. Collaborative decision-making frameworks have been developed to help facilitate delivering care based on patient preferences (patient-centered care). The current value-based health care model, however, focuses on improving population health and overlooks the individuality of patients and their preferences for care. We highlight the importance of eliciting patient preferences in collaborative decision making and describe a conceptual framework that incorporates individual patients’ preferences when defining value. (J Hand Surg Am. 2018;-(-):-e-. Copyright Ó 2018 by the American Society for Surgery of the Hand. All rights reserved.) Key words Patient-centered care, quality, shared decision making, value, value informed by patient.
R
have prompted a reanalysis of the traditional medical decision-making model.1 Historically, medical decision making has been paternalistic, in which the physician alone possesses the technical skills and knowledge required to make medical decisions on behalf of the patient.2 Advancing technologies and shifting cultural paradigms have resulted in the recognition of patient values and preferences as the drivers in medical decision making.3 Collaborative decision-making models, such as shared decision making, provide guidance in making decisions based on patient preferences in order to deliver care that is centered around patient interests (patientcentered care). At the same time, health care delivery is also shifting away from promoting highvolume care toward incentivizing high-quality, ECENT CHANGES IN HEALTH CARE
From the *Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA. Received for publication October 10, 2017; accepted in revised form March 20, 2018. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Robin N. Kamal, MD, Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway St., Redwood City, CA 94063; e-mail: [email protected]. 0363-5023/18/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2018.03.036
low-cost care (high value) that improves health. The current value-based health care model, however, does not account for the individuality of the patient and, specifically, her preferences for various aspects of care. As such, there remains a barrier in implementing care based on patient preferences and in providing high-value care focused on improving quality while decreasing costs. We present a conceptual framework for a value-based health care model that is rooted in providing patient-centered care. WHAT IS SHARED DECISION MAKING? Shared decision making is a collaborative decisionmaking approach that can be broadly defined as a process by which a patient and a physician collaborate to mutually reach a health care decision that is best aligned with patient preferences.3,4 Collaborative decision making places the physician in an educator role, making him or her responsible for providing the patient with the best available information regarding the disorder and its available diagnostic and treatment options. This approach to health care delivery leads to improved patient confidence, treatment adherence, patient-physician communication, cost effectiveness, outcomes, and overall patient satisfaction.5,6
Ó 2018 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
PATIENTS SHOULD DEFINE VALUE IN HEALTH CARE
In shared decision making, emphasis is placed on encouraging physicians to understand and support the individual beliefs and preferences of their patients and to incorporate these into clinical treatment.7 Eliciting patient preferences is critical not only in ensuring that the selected treatment option is in accordance with patient desires and values but also in encouraging enhanced communication between patient and physician, which can augment the process of care.8
costs when surgical and nonsurgical treatment options offer similar outcomes.11e14 LIMITATIONS OF THE TRADITIONAL VALUEBASED HEALTH CARE MODEL The goal of the traditional value-based health care model is to improve quality of care and decrease costs (value ¼ quality/cost) for a population. How quality is defined varies based on the perspective from either the patient, the health system, or the policy maker. For example, policy makers or health systems could define high-quality care as not operating on any distal radius fractures in the elderly (> 65 years) because patient-reported outcomes are equivalent 6 months after treatment by surgery or casting. Such a definition, however, ignores factors that may drive a patient to prefer surgical treatment, such as their activity level or interest in keeping their grip strength— attributes that are associated with surgery instead of casting. When high-quality care is defined broadly, without considering patient preferences, these definitions ignore the individuality of an informed patient and how she or he defines highquality care. Moreover, cost also varies based on the perspective of the patient, health system, or policy maker. Whereas policy makers define costs from a societal or government perspective and are motivated to contain costs for society, health systems and payers define costs in terms of direct medical costs and reimbursement for patient care. The patient perspective on cost, however, is often ignored and includes copays and deductibles (out-of-pocket costs) and indirect costs such as time off work. For example, if 2 treatments lead to similar outcomes, but 1 treatment is costlier to the patient, a financially distressed patient may opt for the less costly treatment based on preferences for cost. Indeed, to fully capture costs, all perspectives should be ascertained and inform the value equation for each individual patient. The drive for health systems and payers to improve value within the current model marginalizes the effect of cost on the patient and leaves many unanswered questions. For example, when additional costs are incurred based on a patient’s preference for care, who should bear the burden of these costs? How should physicians conduct educated cost discussions with their patients? As such, the traditional value-based health care model is limited in its ability to improve value from the patient perspective. Instead of applying
ELICITING PATIENT PREFERENCES IS REQUIRED FOR SHARED DECISION MAKING Eliciting and incorporating patient preferences into treatment decisions is a critical step in shared decision making, especially when there is clinical equipoise in treatment. For example, multiple randomized trials have shown similar functional outcomes between nonsurgical and surgical treatment of distal radius fractures in the elderly. Thus, the decision for treatment should be based on patient preferences for the attributes of each treatment choice (eg, infection risk, risks of anesthesia, cosmetic deformity, loss of grip strength) because each treatment has its own risks and benefits that different patients will value differently. When not elicited, however, patient preferences can be misinterpreted, leading to treatments that are not patient centered. In a study of breast cancer patients, for example, doctors believed that 0% of patients would rate avoiding breast implants as their top priority; however, 33% of patients actually valued this attribute.9 Prior work has demonstrated an elderly patient with a wrist fracture is 5.7 times more likely to be treated by a cast if seen by an orthopedic surgeon than by a hand surgeon.10 A patient that prefers to avoid the experience of surgery and postoperative pain can receive treatment that is misaligned with preferences in a model that does not value preference elicitation and shared decision making. Tools to improve our ability to elicit patient preferences have been developed. One example is conjoint analysis, a quantitative method that helps determine how patients value different attributes (eg, feature, function, risks, benefits) that make up a treatment. In prostate cancer and hepatitis C treatment, conjoint analysis has been shown to increase patient confidence in the treatment decision and lower rates of surgery.11 These cases, in addition to other studies, suggest that decision making based on patient preferences may reduce health care utilization and J Hand Surg Am.
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PATIENTS SHOULD DEFINE VALUE IN HEALTH CARE
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definitions of quality and cost broadly to all patients, individual patients and society may benefit from definitions of value that are formed by individual patients. FIGURE 1: The Traditional Value Model. This model uses definitions for quality (QualityðSÞ ), cost (CostðSÞ ), and value (Value) that are predefined by the health care system and deemed equivalent for every patient. This model does not explicitly consider patient preferences to define quality or value and does not incentivize collaborative decision making.
THE TRADITIONAL MODEL DOES NOT INCORPORATE PATIENT PREFERENCES The traditional model of defining value is suboptimal for discretionary or elective problems, such as surgery for pain and function, where there is often no superior treatment choice. When no superior treatment choice exists, treatment decisions should be solely based on patient preferences for the various attributes of care (eg, experience, risks, benefits, cost). The current model of defining and measuring value applies broad rules to all patients without considering the unique patient values and preferences, minimizing the individuality of the patient. By applying broad rules to all patients, the current model disincentivizes preference elicitation by penalizing physicians when patients choose care that may not be favored by the evidence but is aligned with their preferences. If the traditional value model ignores the patient preferences that drive decisions, then perhaps the model should be reengineered to align assessment of quality, cost, and value from the patient perspective. We believe the value model should focus on ensuring preference elicitation and collaborative decision making, opposed to solely measuring treatment decisions. Defining, measuring, and implementing value-based health care at the patient level, with consideration for patient preferences, is a more patient-centered approach to improving health. In the current health care model, cost is defined as the cost to both the payer and the health system as a whole. In a patient-centered model, cost is defined by the patient’s perspective and preferences for cost, in addition to cost to the health system and society. Prior work we have done in hand surgery found patients have varying thresholds for their willingness to pay out of pocket for different aspects of care (such as smaller scar size, faster return to work). Whereas the traditional value model incentivizes decreasing costs to the health care system, there is no consideration for the indirect medical costs incurred by patients, such as taking time off work or the intangible costs of requiring social support from a family member. Making cost data more transparent to both physician and patient and promoting discussion of these costs could be beneficial in aligning treatment with patient preferences for cost and J Hand Surg Am.
improving value of care to both the individual and the health care system. VALUE INFORMED BY PATIENT FRAMEWORK A new model is needed that (1) ascertains a patient’s preferences for diagnosis and treatment through collaborative decision making, (2) incorporates these preferences in defining quality and cost for the individual patient, and (3) defines value for the individual patient. This new model would define quality, cost, and value at the patient level, with the ultimate goal of improving patient health and decreasing the overall cost to the system and society. Because decisions based on patient preferences improve patient-centered outcomes, this framework should be rooted in understanding and implementing preference-based care.15,16 The current framework for defining value in Figure 1 exhibits value as a variable that is predefined by the health care system. Quality and cost are deemed equivalent for every patient, regardless of preference, and the net value is used to dictate the diagnosis, treatment, and outcome for every patient with a given disease. There is no explicit adjustment or elicitation of individual preferences and the model assumes that most patients value and prefer the same things. The broad definition of quality is used and applied to all patients, resulting in a system that devalues an individual’s own preferences for the various attributes of care. A new Value Informed by Patient Framework in Figure 2 refocuses on the patient as an individual and incentivizes preference elicitation and collaborative decision making. Value is calculated for each individual based on his or her preferences for the various attributes of care—in essence, creating a patient-centered definition of value that may be variable across a population. Patient preferences are elicited along the continuum of care and the model focuses on enhanced communication between patient r
Vol. -, - 2018
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PATIENTS SHOULD DEFINE VALUE IN HEALTH CARE
FIGURE 2: The Value Informed by Patient Framework. This model generates patient-specific definitions for quality (QualityP1 ), cost ðCostP1 þ CostðSocietyÞ ), and value (ValueP1 ), that are collected through collaborative decision making. Because these definitions are constructed based on individual patient preferences, they ensure efforts to improve value are patient centered.
and physician. Prior work on implementation of collaborative decision making suggests that such a model that creates patient-centered definitions of value would also improve value at the population level.
cost of care. By refocusing on the patient through collaborative decision making and preference elicitation, value can be optimized, improving care both from the perspective of the individual patient and from that of the health system as a whole.
FROM CONCEPT TO PRACTICE Vertical implementation of this framework into value-based health care models would require several steps. First, prioritizing patient values and preferences over individual physician opinion and paternalism requires a culture change. Although we are at the beginning of such a shift, further work highlighting the discordance of a physician’s assumed preferences for a patient and the patient’s actual preferences are needed. Reciprocally, patients will need to be engaged and active decision makers in their care. Second, at the physician-patient level, we need processes for eliciting patient preferences that are reproducible, quick, and feasible to implement. Elicited preferences could also generate patient-specific decision aids to facilitate decision making. Third, in parallel to these processes, health systems and payers need to value patient-centered care and the process of eliciting preferences over the decision itself because informed patients may make decisions that are misaligned with broad definitions of quality or cost. Quality measure development would, therefore, focus on ensuring preference elicitation and patientcentered care. Value would subsequently be both patient-centered and also increase based on prior work showing patient-centered care decreases overall J Hand Surg Am.
REFERENCES 1. Patient Protection and Affordable Care Act, HR 3590, 111th Congress (2009-2010). https://www.congress.gov/bill/111th-congress/ house-bill/3590. 2. Will JF. A brief historical and theoretical perspective on patient autonomy and medical decision making. Chest. 2011;139(6): 1491e1497. 3. Oshima Lee E, Emanuel EJ. Shared decision making to improve care and reduce costs. N Engl J Med. 2013;368(1):6e8. 4. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med. 1997;44(5):681e692. 5. Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2011;10:CD001431. 6. Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Med Decis Mak Int J Soc Med Decis Mak. 2015;35(1):114e131. 7. Shared Decision-Making. Available at: https://cahps/qualityimprovement/improvement-guide/6-strategies-for-improving/communi cation/strategy6i-shared-decisionmaking.html. Accessed July 13, 2017. 8. Egbrink MO, IJzerman M. The value of quantitative patient preferences in regulatory benefit-risk assessment. J Mark Access Health Policy. 2014;2. 9. Lee CN, Hultman CS, Sepucha K. Do patients and providers agree about the most important facts and goals for breast reconstruction decisions. Ann Plast Surg. 2010;64(5):563e566. 10. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg Am. 2009;91(8):1868e1873. 11. Arterburn D, Wellman R, Westbrook E, et al. Introducing decision aids at Group Health was linked to sharply lower hip and knee
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PATIENTS SHOULD DEFINE VALUE IN HEALTH CARE
14. Kennedy ADM, Sculpher MJ, Coulter A, et al. Effects of decision aids for menorrhagia on treatment choices, health outcomes, and costs: A randomized controlled trial. JAMA. 2002;288(21): 2701e2708. 15. Barry MJ, Edgman-Levitan S. Shared decision making—the pinnacle of patient-centered care. N Engl J Med. 2012;366(9): 780e781. 16. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10): 1361e1367.
surgery rates and costs. Health Aff (Millwood). 2012;31(9): 2094e2104. 12. Wagner EH, Barrett P, Barry MJ, Barlow W, Fowler FJ. The effect of a shared decisionmaking program on rates of surgery for benign prostatic hyperplasia. Pilot results. Med Care. 1995;33(8): 765e770. 13. Morgan MW, Deber RB, Llewellyn-Thomas HA, et al. Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease. J Gen Intern Med. 2000;15(10): 685e693.
J Hand Surg Am.
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Vol. -, - 2018
Patients Should Define Value in Health Care: A Conceptual Framework Robin N. Kamal, MD,* Sarah E. Lindsay, BS,* Sara L. Eppler, MPH*
The main tenet of value-based health care is delivering high-quality care that is centered on the patient, improving health, and minimizing cost. Collaborative decision-making frameworks have been developed to help facilitate delivering care based on patient preferences (patient-centered care). The current value-based health care model, however, focuses on improving population health and overlooks the individuality of patients and their preferences for care. We highlight the importance of eliciting patient preferences in collaborative decision making and describe a conceptual framework that incorporates individual patients’ preferences when defining value. (J Hand Surg Am. 2018;-(-):-e-. Copyright Ó 2018 by the American Society for Surgery of the Hand. All rights reserved.) Key words Patient-centered care, quality, shared decision making, value, value informed by patient.
R
have prompted a reanalysis of the traditional medical decision-making model.1 Historically, medical decision making has been paternalistic, in which the physician alone possesses the technical skills and knowledge required to make medical decisions on behalf of the patient.2 Advancing technologies and shifting cultural paradigms have resulted in the recognition of patient values and preferences as the drivers in medical decision making.3 Collaborative decision-making models, such as shared decision making, provide guidance in making decisions based on patient preferences in order to deliver care that is centered around patient interests (patientcentered care). At the same time, health care delivery is also shifting away from promoting highvolume care toward incentivizing high-quality, ECENT CHANGES IN HEALTH CARE
From the *Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, CA. Received for publication October 10, 2017; accepted in revised form March 20, 2018. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Robin N. Kamal, MD, Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway St., Redwood City, CA 94063; e-mail: [email protected]. 0363-5023/18/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2018.03.036
low-cost care (high value) that improves health. The current value-based health care model, however, does not account for the individuality of the patient and, specifically, her preferences for various aspects of care. As such, there remains a barrier in implementing care based on patient preferences and in providing high-value care focused on improving quality while decreasing costs. We present a conceptual framework for a value-based health care model that is rooted in providing patient-centered care. WHAT IS SHARED DECISION MAKING? Shared decision making is a collaborative decisionmaking approach that can be broadly defined as a process by which a patient and a physician collaborate to mutually reach a health care decision that is best aligned with patient preferences.3,4 Collaborative decision making places the physician in an educator role, making him or her responsible for providing the patient with the best available information regarding the disorder and its available diagnostic and treatment options. This approach to health care delivery leads to improved patient confidence, treatment adherence, patient-physician communication, cost effectiveness, outcomes, and overall patient satisfaction.5,6
Ó 2018 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
PATIENTS SHOULD DEFINE VALUE IN HEALTH CARE
In shared decision making, emphasis is placed on encouraging physicians to understand and support the individual beliefs and preferences of their patients and to incorporate these into clinical treatment.7 Eliciting patient preferences is critical not only in ensuring that the selected treatment option is in accordance with patient desires and values but also in encouraging enhanced communication between patient and physician, which can augment the process of care.8
costs when surgical and nonsurgical treatment options offer similar outcomes.11e14 LIMITATIONS OF THE TRADITIONAL VALUEBASED HEALTH CARE MODEL The goal of the traditional value-based health care model is to improve quality of care and decrease costs (value ¼ quality/cost) for a population. How quality is defined varies based on the perspective from either the patient, the health system, or the policy maker. For example, policy makers or health systems could define high-quality care as not operating on any distal radius fractures in the elderly (> 65 years) because patient-reported outcomes are equivalent 6 months after treatment by surgery or casting. Such a definition, however, ignores factors that may drive a patient to prefer surgical treatment, such as their activity level or interest in keeping their grip strength— attributes that are associated with surgery instead of casting. When high-quality care is defined broadly, without considering patient preferences, these definitions ignore the individuality of an informed patient and how she or he defines highquality care. Moreover, cost also varies based on the perspective of the patient, health system, or policy maker. Whereas policy makers define costs from a societal or government perspective and are motivated to contain costs for society, health systems and payers define costs in terms of direct medical costs and reimbursement for patient care. The patient perspective on cost, however, is often ignored and includes copays and deductibles (out-of-pocket costs) and indirect costs such as time off work. For example, if 2 treatments lead to similar outcomes, but 1 treatment is costlier to the patient, a financially distressed patient may opt for the less costly treatment based on preferences for cost. Indeed, to fully capture costs, all perspectives should be ascertained and inform the value equation for each individual patient. The drive for health systems and payers to improve value within the current model marginalizes the effect of cost on the patient and leaves many unanswered questions. For example, when additional costs are incurred based on a patient’s preference for care, who should bear the burden of these costs? How should physicians conduct educated cost discussions with their patients? As such, the traditional value-based health care model is limited in its ability to improve value from the patient perspective. Instead of applying
ELICITING PATIENT PREFERENCES IS REQUIRED FOR SHARED DECISION MAKING Eliciting and incorporating patient preferences into treatment decisions is a critical step in shared decision making, especially when there is clinical equipoise in treatment. For example, multiple randomized trials have shown similar functional outcomes between nonsurgical and surgical treatment of distal radius fractures in the elderly. Thus, the decision for treatment should be based on patient preferences for the attributes of each treatment choice (eg, infection risk, risks of anesthesia, cosmetic deformity, loss of grip strength) because each treatment has its own risks and benefits that different patients will value differently. When not elicited, however, patient preferences can be misinterpreted, leading to treatments that are not patient centered. In a study of breast cancer patients, for example, doctors believed that 0% of patients would rate avoiding breast implants as their top priority; however, 33% of patients actually valued this attribute.9 Prior work has demonstrated an elderly patient with a wrist fracture is 5.7 times more likely to be treated by a cast if seen by an orthopedic surgeon than by a hand surgeon.10 A patient that prefers to avoid the experience of surgery and postoperative pain can receive treatment that is misaligned with preferences in a model that does not value preference elicitation and shared decision making. Tools to improve our ability to elicit patient preferences have been developed. One example is conjoint analysis, a quantitative method that helps determine how patients value different attributes (eg, feature, function, risks, benefits) that make up a treatment. In prostate cancer and hepatitis C treatment, conjoint analysis has been shown to increase patient confidence in the treatment decision and lower rates of surgery.11 These cases, in addition to other studies, suggest that decision making based on patient preferences may reduce health care utilization and J Hand Surg Am.
r
Vol. -, - 2018
PATIENTS SHOULD DEFINE VALUE IN HEALTH CARE
3
definitions of quality and cost broadly to all patients, individual patients and society may benefit from definitions of value that are formed by individual patients. FIGURE 1: The Traditional Value Model. This model uses definitions for quality (QualityðSÞ ), cost (CostðSÞ ), and value (Value) that are predefined by the health care system and deemed equivalent for every patient. This model does not explicitly consider patient preferences to define quality or value and does not incentivize collaborative decision making.
THE TRADITIONAL MODEL DOES NOT INCORPORATE PATIENT PREFERENCES The traditional model of defining value is suboptimal for discretionary or elective problems, such as surgery for pain and function, where there is often no superior treatment choice. When no superior treatment choice exists, treatment decisions should be solely based on patient preferences for the various attributes of care (eg, experience, risks, benefits, cost). The current model of defining and measuring value applies broad rules to all patients without considering the unique patient values and preferences, minimizing the individuality of the patient. By applying broad rules to all patients, the current model disincentivizes preference elicitation by penalizing physicians when patients choose care that may not be favored by the evidence but is aligned with their preferences. If the traditional value model ignores the patient preferences that drive decisions, then perhaps the model should be reengineered to align assessment of quality, cost, and value from the patient perspective. We believe the value model should focus on ensuring preference elicitation and collaborative decision making, opposed to solely measuring treatment decisions. Defining, measuring, and implementing value-based health care at the patient level, with consideration for patient preferences, is a more patient-centered approach to improving health. In the current health care model, cost is defined as the cost to both the payer and the health system as a whole. In a patient-centered model, cost is defined by the patient’s perspective and preferences for cost, in addition to cost to the health system and society. Prior work we have done in hand surgery found patients have varying thresholds for their willingness to pay out of pocket for different aspects of care (such as smaller scar size, faster return to work). Whereas the traditional value model incentivizes decreasing costs to the health care system, there is no consideration for the indirect medical costs incurred by patients, such as taking time off work or the intangible costs of requiring social support from a family member. Making cost data more transparent to both physician and patient and promoting discussion of these costs could be beneficial in aligning treatment with patient preferences for cost and J Hand Surg Am.
improving value of care to both the individual and the health care system. VALUE INFORMED BY PATIENT FRAMEWORK A new model is needed that (1) ascertains a patient’s preferences for diagnosis and treatment through collaborative decision making, (2) incorporates these preferences in defining quality and cost for the individual patient, and (3) defines value for the individual patient. This new model would define quality, cost, and value at the patient level, with the ultimate goal of improving patient health and decreasing the overall cost to the system and society. Because decisions based on patient preferences improve patient-centered outcomes, this framework should be rooted in understanding and implementing preference-based care.15,16 The current framework for defining value in Figure 1 exhibits value as a variable that is predefined by the health care system. Quality and cost are deemed equivalent for every patient, regardless of preference, and the net value is used to dictate the diagnosis, treatment, and outcome for every patient with a given disease. There is no explicit adjustment or elicitation of individual preferences and the model assumes that most patients value and prefer the same things. The broad definition of quality is used and applied to all patients, resulting in a system that devalues an individual’s own preferences for the various attributes of care. A new Value Informed by Patient Framework in Figure 2 refocuses on the patient as an individual and incentivizes preference elicitation and collaborative decision making. Value is calculated for each individual based on his or her preferences for the various attributes of care—in essence, creating a patient-centered definition of value that may be variable across a population. Patient preferences are elicited along the continuum of care and the model focuses on enhanced communication between patient r
Vol. -, - 2018
4
PATIENTS SHOULD DEFINE VALUE IN HEALTH CARE
FIGURE 2: The Value Informed by Patient Framework. This model generates patient-specific definitions for quality (QualityP1 ), cost ðCostP1 þ CostðSocietyÞ ), and value (ValueP1 ), that are collected through collaborative decision making. Because these definitions are constructed based on individual patient preferences, they ensure efforts to improve value are patient centered.
and physician. Prior work on implementation of collaborative decision making suggests that such a model that creates patient-centered definitions of value would also improve value at the population level.
cost of care. By refocusing on the patient through collaborative decision making and preference elicitation, value can be optimized, improving care both from the perspective of the individual patient and from that of the health system as a whole.
FROM CONCEPT TO PRACTICE Vertical implementation of this framework into value-based health care models would require several steps. First, prioritizing patient values and preferences over individual physician opinion and paternalism requires a culture change. Although we are at the beginning of such a shift, further work highlighting the discordance of a physician’s assumed preferences for a patient and the patient’s actual preferences are needed. Reciprocally, patients will need to be engaged and active decision makers in their care. Second, at the physician-patient level, we need processes for eliciting patient preferences that are reproducible, quick, and feasible to implement. Elicited preferences could also generate patient-specific decision aids to facilitate decision making. Third, in parallel to these processes, health systems and payers need to value patient-centered care and the process of eliciting preferences over the decision itself because informed patients may make decisions that are misaligned with broad definitions of quality or cost. Quality measure development would, therefore, focus on ensuring preference elicitation and patientcentered care. Value would subsequently be both patient-centered and also increase based on prior work showing patient-centered care decreases overall J Hand Surg Am.
REFERENCES 1. Patient Protection and Affordable Care Act, HR 3590, 111th Congress (2009-2010). https://www.congress.gov/bill/111th-congress/ house-bill/3590. 2. Will JF. A brief historical and theoretical perspective on patient autonomy and medical decision making. Chest. 2011;139(6): 1491e1497. 3. Oshima Lee E, Emanuel EJ. Shared decision making to improve care and reduce costs. N Engl J Med. 2013;368(1):6e8. 4. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med. 1997;44(5):681e692. 5. Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2011;10:CD001431. 6. Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Med Decis Mak Int J Soc Med Decis Mak. 2015;35(1):114e131. 7. Shared Decision-Making. Available at: https://cahps/qualityimprovement/improvement-guide/6-strategies-for-improving/communi cation/strategy6i-shared-decisionmaking.html. Accessed July 13, 2017. 8. Egbrink MO, IJzerman M. The value of quantitative patient preferences in regulatory benefit-risk assessment. J Mark Access Health Policy. 2014;2. 9. Lee CN, Hultman CS, Sepucha K. Do patients and providers agree about the most important facts and goals for breast reconstruction decisions. Ann Plast Surg. 2010;64(5):563e566. 10. Chung KC, Shauver MJ, Birkmeyer JD. Trends in the United States in the treatment of distal radial fractures in the elderly. J Bone Joint Surg Am. 2009;91(8):1868e1873. 11. Arterburn D, Wellman R, Westbrook E, et al. Introducing decision aids at Group Health was linked to sharply lower hip and knee
r
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PATIENTS SHOULD DEFINE VALUE IN HEALTH CARE
14. Kennedy ADM, Sculpher MJ, Coulter A, et al. Effects of decision aids for menorrhagia on treatment choices, health outcomes, and costs: A randomized controlled trial. JAMA. 2002;288(21): 2701e2708. 15. Barry MJ, Edgman-Levitan S. Shared decision making—the pinnacle of patient-centered care. N Engl J Med. 2012;366(9): 780e781. 16. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10): 1361e1367.
surgery rates and costs. Health Aff (Millwood). 2012;31(9): 2094e2104. 12. Wagner EH, Barrett P, Barry MJ, Barlow W, Fowler FJ. The effect of a shared decisionmaking program on rates of surgery for benign prostatic hyperplasia. Pilot results. Med Care. 1995;33(8): 765e770. 13. Morgan MW, Deber RB, Llewellyn-Thomas HA, et al. Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease. J Gen Intern Med. 2000;15(10): 685e693.
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