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Reflections on the Ongoing Struggle to Define Value in Healthcare


How will we define the value of our healthcare system? Dr. Neel Shah considers here and on Wing of Zock. Photo via Christian Delbert/ Shutterstock.

Last week, I had the opportunity to sit at a table with some of the nation’s top thought leaders. We convened at the Newseum in Washington, DC, for the Healthcare Leadership Council’s National Dialogue for Healthcare Innovation; it was like a health policy nerd red carpet. Center for Medicare Director Sean Cavanaugh was there. Leapfrog Group CEO Leah Binder was there. America’s favorite bioethicist – oncologist – provocateur Zeke Emanuel was there. The chief executives of providers, payers, pharmaceutical companies, government agencies, all there. And what were they there to do? Define “value” in health care.

Really. In 2015.

Don’t get me wrong – everyone there, including myself, felt this was a worthy goal. What’s lamentable is that it remains such a struggle to get this done, particularly in an era where the Internet has made transparency ubiquitous and value obvious in every other industry. In the morning, the illustrious group quickly converged around a functional definition: value equals quality divided by cost, preferably at the clinical condition level. Fine. But then the discussion became more nuanced.

The more macro-economically inclined pointed out that the United States fails to deliver value (using our working definition) compared to peer countries. The technologists balked. We create amazing things: Mayo Clinics, proton beam facilities, medicines that cure hepatitis C. Surely there is value in that? I saw their point. While our European counterparts are well optimized to take care of the “average” patient for whom our value equation is designed, the United States is optimized to take care of the “exceptional” patient. Perhaps the Mayo Clinic doesn’t have an equivalent across the pond for a reason, and perhaps our definition of value should account for the fact that we prefer to create amazing things.

As the discussion evolved, it became clear that innovators and implementers were thinking about the value equation differently. It also became clear that, somewhere, along the arc of progress from developing an exciting new technology to deploying it at the patient’s bedside, a critical failure was happening. As a result, opportunities to generate value through innovative technology repeatedly attenuate when we try to apply them to patients. That is what we needed to get our heads around. That is what payment reform and delivery reform need to solve.

As it turns out, not everyone needs to go to the Mayo Clinic or use the latest and greatest technologies. But then again, some do. Without a well-coordinated health system, we’re unable to match our capabilities up with our needs on a patient-by-patient basis.

As we passed the microphone, there were a few rays of hope. Health and Human Services Secretary Sylvia Burwell established a timeline last month for moving the American health care payment system from volume to value; this was mentioned several times as an important catalyst for change. Also mentioned were the demonstrations of true delivery reform among a few pioneering organizations—providers who were navigating the complexity of the current system to deliver risk-appropriate, high-value care.

Emanuel put it best it in a typically wry fashion: to move forward we need to “stop beating a dead fish.” Just as there are many examples of what doesn’t work, there are also shining examples of what does work. To preserve the value of promising advances in American medicine, the nation’s health care leaders need to look hard to find these positive examples, support them, and bring them to scale.

This post comes from our content partnership with Wing of Zock. Read more of their content here.

Neel Shah, MD

Neel Shah, MD

    Neel Shah is the executive director of Costs of Care, an independent nonprofit that helps patients and their caregivers deflate medical bills. He is also an ob/gyn based at Beth Israel Deaconess Medical Center and an investigator at Ariadne Labs. He can be reached at neel@costsofcare.org.

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    1 Comment

    1. Here’a a question: where there any actual current users of the system in the room, participating in this discussion?

      As compelling as it is to hear Zeke Emanuel’s colorful exhortation relating to to the abuse of dead fish, it’s much more compelling – and change-driving – to have the end-user around to deliver real-world/real-time insights to the occupants of the ivory tower.

      I wear a couple of hats in this arena, since I cover hospital medicine as a journalist and have somehow managed to be tagged as a patient engagement expert by the WHO, while also being solidly in the “plain old patient” row as a deeply experienced navigator of the medical-industrial complex as a patient (cancer) and family caregiver (Parkinson’s, dementia, and more).

      Given that close to 360º perspective, I have to say that much of the #epicfail in ID-ing value in US healthcare can be laid at the door of forgetting to include patients in every conversation about care setting design, quality improvement, cost management, and more.

      So … did you let patients help? Or was it another conversation that was limited to “grownups only”?

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