Author + information
- †Department of Internal Medicine, Division of Cardiovascular Diseases, University of Michigan Health System, Ann Arbor, Michigan
- ‡University of Michigan School of Public Health, Ann Arbor, Michigan
- §Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, Michigan
- ‖Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan
- ↵∗Reprint requests and correspondence:
Dr. Daniel M. Alyeshmerni, Department of Internal Medicine, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109.
“Nowadays people know the price of everything and the value of nothing.”
—Oscar Wilde, The Picture of Dorian Gray (1)
The United States spends too much on health care and gets too little in return. Major public policy efforts, such as the Medicare shared savings and value-based purchasing programs, have been launched in recent years with this recognition (2). Private initiatives like the Choosing Wisely campaign similarly seek to reduce unnecessary spending through a pursuit of higher value care (3). Nonetheless, basic issues related to measuring and quantifying value in health care, defined as quality for a given level of cost, remain unresolved (4,5). This is due, in large part, to limitations in the evidence base and measurement systems for implementing a value-based care strategy. For many procedures and treatment regimens, best practices are not well defined and data for the cost and outcomes needed to assess value are often unreliable.
It is in this context that the paper by Ho et al. (6), in this issue of the Journal, makes a significant contribution. The study evaluates cost variation and quality of care among patients receiving a percutaneous coronary intervention (PCI) in 60 U.S. Department of Veterans Affairs (VA) hospitals. One year after PCI, the authors found relatively little variation in mortality but large variations in PCI-associated costs (ranging from 55% below median standardized costs to 209% above median standardized cost). Not surprisingly, given these global findings, the authors also found that PCI costs had no correlation with mortality.
In many ways, PCI, a common and costly procedure, was an excellent procedure on which to focus their investigation. Despite the unparalleled development of clinical effectiveness evidence in cardiology, there remains significant uncertainty about the value of many cardiac treatments. The American College of Cardiology/American Heart Association only recently produced the official Statement on Cost/Value Methodology in Clinical Practice Guidelines and Performance Measures (7). This statement recognizes the historical reluctance to include explicit considerations of cost in practice guidelines, although the authors acknowledge costs have long been implicitly considered. This statement proposes a series of “level of value” categories; the primary barrier it cites for proper application of these categories is the lack of high-quality data for the cost and value of interventions and procedures used in practice. More is known about PCI than many other therapies, allowing for good investigations of value, like that of Ho et al. (6). Evidence suggests that in the appropriate context (e.g., ST-segment elevation myocardial infarction [STEMI]), PCI saves lives and is cost effective (8–10). On the other hand, other data indicate PCI (and coronary revascularization in general) is over-provided in the United States and is not related to improved outcomes in many patients (11). By showing that variations in the costs related to this important procedure are significant and unrelated to outcomes, this study informs the value discussion, particularly in understanding the costs over time and the health of this population.
One strength and limitation of the study by Ho et al. (6) is the 1-year follow-up period. Although longer-term outcomes like 1-year mortality and costs are more relevant to patients and the health care system, this longer observation period makes it challenging to attribute the overall findings to the receipt of PCI alone. Many therapies, such as the use of optimal medical therapy, play a role in mortality and resource use over this time period. This raises the question should value be assessed for short-term gains of PCI or its long-term implications for patients over 1 year (or even a life time)? This is especially important and difficult to determine for a procedure like PCI, where alternative treatments frequently exist. The time period over which costs are measured should be guided by the clinical context (e.g., STEMI vs. stable angina) and is another fertile area for further study.
The VA patient population examined in this study is also a unique feature, and thus, its findings may not be generalizable to other patient populations. The VA health system is organized and funded differently than most health care facilities and systems, and it may not reflect costs for other health care providers. However, because of this the study findings are all the more significant. VA hospitals tend to have greater restrictions on spending and utilization than outside, non-VA hospitals, and their cardiologists are incentivized differently as they are not reimbursed in the traditional fee-for-service model still prevalent in the United States. As a result, it is reasonable to assume that VA hospitals would have lower rates of inappropriate PCIs than hospitals caring largely for patients with Medicare or private insurers. If PCI-related costs are not related to outcomes within the VA, costs are unlikely to be related to outcomes outside of the VA.
It is also unique that the VA system tracks associated costs, as opposed to charges or billed services. This uniform cost accounting system allows for more precise comparisons between hospitals, which reflect actual differences in resource utilization for a procedure, rather than differences that are intentionally generated for payments that may reflect regional wage disparities, cost of living, illness severity, or expense of caring for underinsured patients. As previous investigations have illustrated, these intentional modifiers can be substantial when using other data sources, and they must first be removed or accounted for to accurately quantify variations in utilization across hospitals (12).
Another important issue is that of choosing the correct outcome when assessing value. Although Ho et al. (6) analyzed an inarguably important clinical result of mortality, this is far from being the only endpoint of interest. Given its low mortality rate in contemporary practice, other outcomes such as complications, symptoms, and functional status are better suited for assessing quality in PCI (13). As patient-reported outcomes (e.g., angina burden, quality of life) and appropriateness are readily available for PCI, the possibility of creating a more robust definition for value in PCI is enticing. Combining such outcomes and converting them into a standard unit, such as quality-adjusted life years, would provide much more useful and interpretable information with which to assess value and allow direct comparisons to alternate treatments. Such a framework for cost effectiveness analysis and efficiency studies has long been used in cardiology, and these tools should not be forgotten in our new efforts to measure value (14).
A final issue that policy makers will need to consider is the right context for assessing value in health care. Should value be defined for a given procedure (e.g., PCI), a disease entity (e.g., coronary artery disease), or population (e.g., veterans)? If value is studied in relation to coronary artery disease, then the outcomes and costs of multiple management approaches (e.g., medical therapy or surgical revascularization) must be considered. If value is examined in a population of veterans, other competing comorbidities and their treatments come into consideration. By evaluating the cost and quality for only those patients who received PCI, Ho et al. (6) do not address the essential question of whether PCI should have been done in the first place. Would either medical management or coronary artery bypass surgery have been better than PCI? This is a not a trivial issue. Indeed, performing PCI on a young, asymptomatic patient with a straightforward but physiologically insignificant coronary lesion would likely achieve low mortality at little expense but with no expected benefit. Safe and low-cost care, it turns out, can also be of extremely low value.
These challenges aside, the study by Ho et al. (6) is a positive step forward. It informs the national discussion of value in an important population of patients undergoing PCI, particularly highlighting the need to evaluate both costs and quality of care for populations over time. With the ongoing implementation of the Affordable Care Act and undoubtedly a broader emphasis on new payment models, such as accountable care, the time for moving forward with value measurement has never been more important. The idea of applying these concepts to insurance design and copayment has already been shown to be cost neutral (15).
As debate continues on how to reorganize health care, including how services may be best reimbursed, it is useful to recall Oscar Wilde’s characterization of the cynic who knows “the price of everything and the value of nothing.” Changes in health care policy should strive to improve the intrinsic value of care, not solely its cost profile. This will require that the ideal value-based health care strategy pay close attention to the precise measurement and relationship between a range of clinical outcomes and expenditures. If we as a medical community ever lose sight of these goals, we will be no better than cynics.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Wilde O.
- ↵CMS considers future measures for the Efficiency and Cost Reduction domain in the FY 2015 IPPS/LTCH Proposed Rule. April 2014. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/Downloads/Hospital-Based-Episode-Measures-Supplemental-Documentation.pdf. Accessed July 3, 2014.
- ↵Choosing Wisely: an Initiative of the ABIM Foundation. October 2014. Available at: http://www.choosingwisely.org/. Accessed October 12, 2014.
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