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July 23, 2013
What's value in health care?

I was recently involved in a conversation about health care reform and value-based care. It was an interesting conversation to say the least, one that revealed fractious lines between what we see and what we get, our vision of health care vs. the reality. But it also revealed a deeper question, one that needs a bit more exploration: What exactly constitutes “value” in health care?

The Merriam-Webster dictionary defines value as 1) “a fair return or equivalent in goods, services, or money for something exchanged”; 2) “the monetary worth of something”; 3) “relative worth, utility, or importance.” (There are other definitions that are not germane to this conversation).

Look at the qualifiers of those definitions: fair, relative, all very nebulous terms, particularly in terms of health care. What is the relative worth, utility or importance of getting a whole body CT, or of ordering daily blood cultures or treating low-grade fevers with antipyretics? What is the fair return or equivalent of a long-term hospitalization or a readmission 10 days later? Or of the obligatory ceftriaxone dose when leaving the emergency department, no matter the diagnosis?

And that’s really the root of the debate.

We’re in the process of transforming payment strategies for health care, switching from a fee-for-service model to one that is value-based. But what does that mean? In practice, it means that the government (and private insurers) who until now have paid for volume of care will start paying for care value instead.

But what we are trying to define is not so much the value of health care, but another analogous term: quality.

And for that, I have to get in my time machine and surf the time-space continuum to a very groovy era—the mid 70s—and fetch a copy of a book called “Zen and the Art of the Motorcycle Maintenance.”

I know what you’re thinking. You thought I was going to quote the latest from the Harvard Business Review or Forbes or the Wall Street Journal.

But what is medicine if not the fulcrum that balances all disciplines? Enter groovy 70s philosophy.

In "Zen," Robert Pirsig argues that people tend to view the world and their experience through one of two prisms: the rational (science, technology) or the romantic (creativity, artistry, intuition).

But he believes that quality is a third way, an unknowable yet recognizable aspect of the universe that combines both points of view and philosophies. According to Pirsig, everything revolves around quality, but one cannot define it: You know it when you see it. For example, when you hear a great piece of music or savor a delectable desert, the sensations and understanding generated by the interaction between those perceptions and the brain are quality.

So how can we achieve quality in health care? In the book, the motorcycle is a metaphor for an interconnected system that one needs to handle to be able to understand it. Likewise, medicine is an interconnected enterprise that needs to be experienced to recognize quality.

Quality is there in health care; we know it when we see it. The various ways that different regulatory and financial bodies (like Medicare, NCQA, etc.) try to make us visualize quality can be clunky and artificial. But the reality is that if a patient leaves the hospital alive, in one piece and with no complications, that is quality. Is that setting the bar too low? Sure, but we have to start somewhere.

Now, “quality” measures that address everything from preventive care to resource utilization are popping up everywhere. What’s a health provider to do?

Perform what you’ve been trained to perform. If you do it honestly, with the innermost realization that the care you provide is quality, then you’ll be fine.

Is that too metaphysical for you? Well, think about it. When you care for patients, you are incentivized by your salary, your aspirations, your debt or your fear. Whatever propels you out of bed each and every day to see patients, be it altruism or terror, it leads you into that exam room. There, deliberations on health care hinge on the balance between your mastery of the rational and the intuitive at every moment, sometimes by the movement of your pen or your cursor.

So, the moment you start writing for that very expensive antibiotic when you know there is a cheaper, equally effective version, or you order that test that won’t give you an actionable answer or make the patient better sooner, ask yourself, “Is this quality?”

Before you know it, you will see it. And if you don’t see the Zen in it, someone else will help you see it. Wouldn’t you rather achieve medical Zen through your own freedom of choice?
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2 Comment(s)

Jeff Bennett wrote:
It is both thrilling and daunting to begin "seeing" value from the patient perspective. My training certainly never articulated this, other than to say "primum non nocere" 5 times real fast.

Every order I write triggers a chain reaction. It lands in someone's work queue, which sets into motion a set of actions. So if I'm a patient with difficulty breathing, the "value" of getting a chest X-ray is the opportunity for my doctor to help me better understand the problem and offer solutions. Everything that happens between the decision to get the X-ray and that moment of discussion with my doctor isn't actually valuable (and only some of it is necessary). Or if I am getting a knee replacement after years of worsening pain and impact on my life, the value comes the day I can walk again with no pain. If it takes 2 weeks in one center and 3 days in another ... easy choice for me, hopefully my doctor, and probably for the payer too.

But how will we know the best choice? And what about cost? The absence of transparency about actual cost and outcomes (info our hospitals have but don't share unless compelled) coupled with "value" being objectified in ways distant from the patient experience mires us in the circular thinking of our current age. Taking up Ruben's challenge will require unprecedented cooperation among policy makers, insurance companies, business interests and health care systems. The data are there,so we need to be able to share it (trust) and work together with a focus on value in terms that actually matter to the people we treat (clarity). Yes, triggering a debate about "want vs. need" is a logical phase of the dialogue that would follow, so blog on my friends!

Thanks Ruben. Cheers!
Lexington, KY | Fri, Jul 26 2013 21:51 PM

Levy Cruz wrote:
Excellent information and comment about ACA reform. Also, quality improvement and lower medical costs in our system are a concern to all.
Hollywood, FL | Thu, Sep 12 2013 07:15 AM

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About Ruben J. Nazario, MD
Ruben J. Nazario, MD, is now medical director at Inovalon, a health care data analytics company, and is medical editor for Elsevier's First Consult. A pediatric hospitalist, Dr. Nazario is a veteran of both community and academic pediatric hospitalist programs. All material represents his own views and does not reflect the views of his employer.
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