When Value Is Valueless

March 6, 2015

What if we paid for everything based on value?

The hype-machine seems to have kicked into high gear about transitioning health care funding to a system based on “value.” And, as usual, we who stand to be most strongly impacted have no idea what it means. Hardly surprising, because those proposing this Big Change don’t know, either.

That’s not to say folks don’t have an opinion or three about what value should mean in this regard. Along with varying degrees of recognition (and occasionally, respect) that other people have differing ideas on the matter with just as much validity, and perhaps even greater practicality.

For instance, on the subject of medical imaging, a radiologist might say that value centers on the right modality of imaging being done with the right technique for the right clinical scenario. With pertinent details of said scenario supplied in the request for imaging supplied by the referring clinician.

Meanwhile, an ER PA who orders a dozen CTs an hour might believe that value hinges on “throughput,” with time taken to administer contrast, provide a clinical history more elaborate than “R/O path,” or, God forbid, see and examine patients before imaging them all being value-reducers.

A hospital administrator might have yet other notions regarding value, notions far removed from what any of the clinically-active staff consider important for patient care. To the point that even departments otherwise in opposition on multiple issues are brought into relative solidarity against the nonsense flowing down the chain of command to them.

Increase that effect an order or two of magnitude when considering how alien “value” becomes as dictated from state or national capitals, by politicians or their appointed bureaucracies. One starts to wonder how much of the value being bandied about at this level still pertains to patients, rather than the next campaign for reelection.

Still, whether some sort of consensus manages to emerge, or the latter players do their usual and shun input from actual providers of health care before imposing new rules of the game, let’s pretend a true “value” based system gets put in place.

I daresay there’s zero consideration for how this health care Utopia will interface with the rest of the real world which surrounds it. While, say, an imaging center might be reimbursed on changing-by-regulatory-fiat definitions of value, everybody the center must transact with for routine operations will not. Equipment manufacturers, contractors doing work on the building, even local municipalities and their assorted taxes will continue to operate outside of the artificial value universe (Valuverse?) according to the realities of their own bottom lines.[[{"type":"media","view_mode":"media_crop","fid":"32789","attributes":{"alt":"Eric Postal, MD","class":"media-image media-image-right","id":"media_crop_3030241768206","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3461","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 194px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Eric Postal, MD","typeof":"foaf:Image"}}]]

Don’t get me wrong; I’d sure like to pay my auto mechanic, plumber, landscaper, and supermarket based on value. If my car gets a few hours’ worth of work done on it and it still doesn’t work properly, I would very much like to have the shop beholden to put in as much additional time and effort as it takes to set things right, with my final bill not getting hiked in the process. If my local store fails to have good broccoli on the shelf and I wind up making do with some other sort of produce, I would love to be able to penalize them by paying less when I get to the checkout line.

And let us not forget one other factor which will exist outside the sphere of value-influence, yet impact heavily upon it: Patients. Their outcomes are routine elements of most value-based schemes I have seen, such as monitoring HbA1c levels in diabetics or BMI values in obesity cases. Measurements that don’t show progress according to the value-rules result in diminished payments to these patients’ physicians…yet a doc can do everything superlatively well and the patient can still choose not to comply.

It seems hard to imagine that all of these factors have escaped the notice of the presumably smart folks eager to lead our health care parade into the value-based Promised Land. Which makes one wonder whether it’s all just another song and dance as a pretext for future cuts in payment, and grabs for ever more power and control by bureaucrats who have no business getting between patients and their doctors.