Clinical Scenario
You have practiced for 24 years in a solo comprehensive otolaryngology–head and neck surgery practice in a medium-sized community. You have developed your office practice into an efficient one, and you have received positive feedback from your patients. A good part of your pleasure in practicing otolaryngology comes from your relationship with patients of all ages, and you believe that your patients are generally happy with their care.
You were contacted yesterday by a representative of a new patient care organization in town that uses “value-based care” concepts and technology. You were invited to become part of the “care team” as a specialist. You have a reasonable understanding of the principles of value-based healthcare, but you need to learn more about the details, and invited the representative to your office today for further discussion.
The discussion started like this:
Ms. Dearborn: Dr. Smith, I am so pleased you could see me today to discuss your joining our organization’s team of specialists. I hope you had a chance to review the information brochure I emailed to you.
Dr. Smith: Thank you for coming by on short notice, Ms. Dearborn. Yes, I did review the detailed brochure and feel I understand the technical, cost-effective, and outcomes-based elements of the plan. But I do have some questions that pertain to quality of care under this value-based approach. I would like to know the improvements to quality of care from the patient’s perspective that are integral to your plan. My patients value the quality of care I provide them, and I strongly believe that is important to many patients across the country.
Ms. Dearborn: Of course, Dr. Smith. Our plan is heavy on quality care, ranging from reducing the cost of care to the patient and the healthcare system to utilizing the highest level of technology to streamline their care using artificial intelligence-based algorithms. Besides, you must be a good physician, and you already deliver quality care, so you don’t need to be concerned about quality when your patients are receiving high-value care.
Dr. Smith: Hmm. Does your value-based care system actually address quality of care from the patient’s perspective? My patients and I care about quality.
Discussion
Although clearly a hypothetical situation, this may serve as a cautionary tale for the prioritization of high-quality care as value-based care undergoes functional development. Nearly all definitions of value-based care use identifiers such as best practices, outcomes measurements, care control and improvement, effective and efficient care, and financial value in delivering healthcare. To date, however, there has been no clear agreement on an accurate definition of either value or quality in healthcare delivery. It’s likely that otolaryngologists believe they are better able to define high-quality care of their own patients in a manner that must be inherent in a value-based system.
In 1965 and on the eve of my entrance to medical school, I remember President Lyndon Johnson signing into law the bill authorizing the formation of Medicare and Medicaid. The signing was performed at the Harry Truman Library in Independence, Mo., out of respect for the former president’s proposal 20 years earlier that set the stage for this major step in government healthcare provision. Many physicians, as well as organized physician groups such as the American Medical Association, were strongly opposed to the establishment of Medicare and continued to be for years thereafter. Over the decades, American physicians have come to accept the concept of government health insurance plans, especially when coupled with private insurance options.
Due to the heavy financial burden of health costs and the recognition that clinical decision making can be guided, in good part, by best practices, outcomes, and cost accounting, a number of iterations of governmental healthcare financing have ensued. Most recently, evidence-based care has become the beacon for anyone linking outcomes to treatments based on evidence. Critics of evidence-based care posit that physician experience and judgment, along with patient perspectives and self-knowledge, must also be strong elements of any newly developing healthcare financing and practice control system. This requires the recognition that patients want value and quality to be aligned with and representative of their holistic needs within the context of their lives and health issues.
While proponents of value-based care indicate that the cost savings and efficiency of the system are inherently quality based, it remains to be seen how that will play out at the patient–physician relationship level. Given that a patient’s physician is the entity most likely to best understand what quality of care and quality of life mean to patients in the therapeutic setting, the responsibility to represent the patient’s best interests and holistic needs in their care rests with that physician.
A New Fee System
The transition from fee-for-service healthcare to another financial methodology has always been a challenge in the U.S. healthcare system. As a former educator in Comparative International Healthcare Systems in a physician executive MBA program, I have studied successful patient-focused payment systems around the world. While expectations are high in the healthcare provider sector that value-based care will indeed live up to promises to improve quality of care for individual patients, it remains to be seen how that will actually occur. The high quality of patient care delivered by caring, knowledgeable, and competent physicians must always be a goal, for that is the expectation of our collective patients. Because value-based healthcare is nominally primary care oriented, otolaryngologists will likely remain consultants within a team of providers who are oriented toward specific clinical conditions that require interdisciplinary and coordinated goals. Such team care will be a larger part of the plan for value-based care than is currently in place. Coordination of patient care could certainly be more efficient and effective and is a salutary goal for the American healthcare enterprise.
Patient care is much more complex than providing “the best bang for the bucks.” In contemplating value in value-based care—because the main impetus to design a new healthcare payment system is, well, financial—it becomes the responsibility of physicians and other providers to identify the proper quality measures that mirror what the patient needs and deserves, and how physicians wish to care for their patients. Some quality care measurements use analog measurements of waiting times, fresh copies of magazines in the waiting room, cleanliness of the office, staff and physician attitudes, and so forth. While these can be measures of something, they are not reliable measures of high-quality care. Quality care of patients in my perspective is much more personal, involving empathy; caring; effective communication; an understanding of the patient’s personal needs and challenges in life, the environment in which they live, their social and family support, what elements in their life they truly value, and what they will accept as changes to those things important to them; and, importantly, the strength of the patient–physician relationship.
Focus on Quality of Care
Otolaryngologists are fortunate to have the opportunity to treat patients of all ages, of all backgrounds and cultures, and often for extended periods of follow-up. We also treat entire families and generations of families. We see our patients at social gatherings, religious services, movie theaters, restaurants and ice cream parlors, and perhaps even at sporting events. We often live where the patients live, whether we practice in rural or urban areas, and it is through these casual interactions that we can gain more context into a patient’s life and activities. Otolaryngologists are the “general practitioners” of disorders of the upper aerodigestive and neurosensory systems. These observations are meant to emphasize our capabilities to understand our patients, to listen to what qualities they “value” in their lives, and to learn what they hope to receive in terms of quality of care according to their individual needs. This could be called a “holistic” approach to care, a term beginning to come into better focus for the medical profession.
So, as this new development of value-based care begins to take form and function, it’s the physician’s responsibility to study and query that system of healthcare to identify shortcomings in how quality—from the patient’s perspective—is being introduced into this high-tech, algorithmic-intense system. The otolaryngologist’s focus is, and should always be, on high-quality care, which is primarily understood in the context of individual patient needs and perspectives, not from artificial intelligence-generated guidelines. Fortunately, the specialty of otolaryngology already has great evidence-based—but also patient-focused—best practices and guidelines for high-quality care, which must be compared to any mandates in a transitioning system. In addition to efficiency, effectiveness, and cost control, we need to always keep high-quality care as the top priority, because we know our patients better than the system does.
As a bioethicist, I have the responsibility to examine and identify any concerns that are ethical in nature and inconsistent with the highest professional standards of patient care. After assessing what we now know about value-based healthcare proposals, my position would be that a more appropriate name for high-value care, keeping in mind the patient’s desire for high-quality care, should be “values-based healthcare.”
Dr. Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.