Last Thursday’s NEJM has several very important articles.  In this post I want to focus on What Is Value in Health Care?    This thoughtful piece really demonstrates how challenging this topic is.  Everyone should read this free article.  I will provide a few quotes to whet your appetite.

… Since value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered, and shifting focus from volume to value is a central challenge. Nor is value measured by the process of care used; process measurement and improvement are important tactics but are no substitutes for measuring outcomes and costs.

The author clearly understands that process measurement is insufficient.

Because care activities are interdependent, value for patients is often revealed only over time and is manifested in longer-term outcomes such as sustainable recovery, need for ongoing interventions, or occurrences of treatment-induced illnesses. The only way to accurately measure value, then, is to track patient outcomes and costs longitudinally.

We cannot declare victory if we lower the HgbA1c or the LDL.  We may be helping the patient, but perhaps we are not.

… There is no substitute for measuring actual outcomes, whose principal purpose is not comparing providers but enabling innovations in care. Without such a feedback loop, providers lack the requisite information for learning and improving.

The article thus sets an extremely high standard.  We use process measures because they are tractable and easier to design.  But we have too much evidence that these measures are insufficient.

I fear, however, that at the end of the paper the author has made the case for an almost unachievable system.  He wants us to collect multiple measurements on each patient.  His structure has great complexity and sophistication, but is it achievable.  He changes the focus appropriately to the patient as the unit of analysis.  Herein he defines the problem.  Patients often have multiple physicians.  They may use emergency departments, walk-in clinics and hospitals.  If we had well defined health systems perhaps we could measure patient outcomes for the system.  But few patients come to health systems, they go to physicians or hospitals.

The task has another level of sophistication that makes this idea even more difficult.  Our patients often suffer from multiple diseases.  These diseases and their treatments have even more interactions that will influence the multiple outcomes we should measure.

Can we measure value in health care?  We can possibly do it if we restructure our health care into true accountable systems.  Perhaps accountable care organizations will be the answer to the question of how we can improve value.  Perhaps …