Tuesday, November 30, 2010

Value or Quality: Still Confused?

There is the ever growing use of terms, value and quality are my favorites, in health care that are euphemisms for cost containment. Why not just make patients pay across the board so that they personally see what the costs are, pay some amount not necessarily all.

Take a recent article in Kaiser about value. It starts with:

What if, instead of making a $10 insurance copayment for your cholesterol lowering drug, your employer provided it and other drugs to manage chronic conditions for free? What if your company also paid for weight management and smoking cessation classes? You'd probably give your employer high marks for looking out for your health.

Now, what if your employer said that if you want certain procedures that it's determined are overused, like an MRI or knee surgery, you'll have to pay up to $500 extra, on top of your other coinsurance charges? Those employer decisions might not be nearly as welcome.

Frankly the patient should be penalized for obesity and smoking, they should be taxed to pay for their added burden, which smokers are already. As for procedures, it depends, and yes some payment should be made. Now enter value, perhaps it takes the place of quality. The article states:

Mercer, a benefits consulting company, found in a 2008 survey that 19 percent of employers with at least 500 employees were charging workers less for services the companies considered to have a higher value for workers' health.

Well what is value and who determines it? The problem is that as we have argued again and again that each patient is different and thus value is a personal calculation, and then we enter the realm of valuing the individual, by some person or persons who have little if any expertise or value themselves. That is how we get denial. That is how we start rationing.

They continue:

Indeed, experts agree that eliminating financial barriers alone isn’t enough to ensure that people stick with their medication regimens, get necessary preventive screenings and high-value medical care. Health coaching and other support services are also critical, says Eric Grossman, a senior partner at Mercer.Nearly all employers and insurers who have adopted value-based insurance benefits to date have done so by dangling the promise of free or reduced-cost benefits, often medications, before consumers.

There is also the role of individual responsibility. The question is value for whom and at what cost. How does this value approach compare to the quality approaches we have been seeing. Is this a "Nudge" approach to medicine?