Value: In the Eye of the Stakeholder

By Heather Rothrock, MBA, PCMH-CCE

The shift from quantity to quality has, in many ways, overhauled the health care industry, with noticeable effects across the spectrum from patients to providers. Originally aimed at fulfilling the quadruple aim—improving population health, enhancing the patient experience, reducing cost, and improving provider satisfaction—most would agree the shift was well-intended, though maybe not always well received. 

Perhaps the most foundational concept driving this transformation has been to provide value. But by whose definition?

Too often, efforts to quantify value in health care are overshadowed by what’s available to measure, are usually outcome-driven, and are externally motivated by payers or other performance monitoring stakeholders. Unfortunately, what is considered “valuable” often varies by audience and becomes even more granular at the individual level.

Though we may never unanimously agree upon what is most valuable in health care (or otherwise, for that matter), it’s important to consider varying perspectives so that we might move closer to meeting expectations.    

Defining Value

At its most fundamental, Merriam-Webster defines value as “the monetary worth of something”; “a fair return or equivalent in goods, services, or money for something exchanged”, and “relative worth, utility, or importance”.  Similarly, the health care industry most often conceptualizes value as an expression of quality over cost and incorporates this as the basis for operational decisions, both large and small scale.

But what does this mean to the patient? How does a patient conceptualize and operationalize value as they approach their own health care?

To begin answering these questions, let us first take into consideration a study by the University of Utah Health in partnership with Leavitt Partners. This particular study examines differences among three of the most prevalent stakeholder groups in healthcare: consumers/patients, providers, and employers. The University based the study on the value equation mentioned above, but with the addition of a third component: service. Otherwise considered the patient experience, service was incorporated as a factor of the equation to activate patients as an equal contributor in determining value. The new equation is written out as follows:

Patients, Providers, and Employers: Who Values What

At a national level, the University of Utah Health study found that among patients surveyed, 62% selected quality (defined as “the efficiency, effectiveness, safety, and results or outcomes of the care I receive”) as the most important of the three components, followed by cost (26%), and finally, patient experience (12%). Quality proved even more important among patients 65 and over, with 76% of this population giving it the top spot.

This trend continues upward among physicians, with 88% responding that quality is the most important component of value in healthcare, followed by patient experience (7%) and cost (5%).

However, employers actually reported the opposite, with 43% indicating patient experience as most important, cost a close second (37%), and quality ranked last (20%).

Additionally, when asked what is most valued when receiving services from a health care provider, patients’ top five selections were:

Provider focus was largely different, as evidenced by their responses that the top five indicators of value in the care they provide were:

It’s remarkable that between these lists, patients and providers only share an interest in the provider knowing and caring about the patient. The providers’ other priorities appear much farther down the list for patients.

This is further illustrated in another important finding within this study: Patients believe responsibility for the improvement of their own health is split between themselves and the physician, while physicians largely assign this responsibility to themselves. Different still is the employer belief that the bulk of improving health lies with the patient.

Two priorities that were identified by patients but not selected by providers were priorities regarding access or the ability to schedule timely appointments and convenient locations. With roughly 20% of the U.S. population living in rural areas, and only 9% of the nation’s physicians practicing in these areas, the convenient location line item is easily neglected.

However, telehealth initiatives intend to reduce these disparities, allowing providers to engage with patients through mechanisms like video conferencing and remote monitoring. Though this technology is relatively new, there are multiple campaigns and initiatives aimed at increasing use and usability in hopes that patients and providers will become more comfortable and find value in this service.

In addition, quality improvement programs like Patient Centered Medical Home (PCMH) aim to improve access by way of offering same day appointments, extended hours, etc. If orchestrated correctly, this allows a practice to better balance their capacity and panels while also creating a value proposition for patients.

Among the other patient priorities, two speak directly to the provider-patient relationship: Having confidence in providers’ expertise and having a more personal relationship with the provider, wherein the patient feels as though the provider knows them well and cares about them. Along these lines, providers indicated knowing and caring about the patient as well as spending sufficient time with the patient among their top values.

There is concern that value-based strategies themselves take away from the provider-patient relationship. A 2018 Future of Healthcare report explains that 43% of physicians surveyed believe value-based care negatively impacts the provider-patient relationship due to an inability of pay-for-performance arrangements to account for personal elements. They also cite the fact that value-based care is often more heavily focused on the population-level rather than the individual. 

Additionally, the same report noted that 54% of physicians believe that the distractions and burdens inherent with using an electronic health record (EHR) are further detrimental to the provider-patient relationship.

Though we can expect EHRs to be around eternally, it is encouraging that they are becoming more intelligible, with more opportunity for automation through functions like Clinical Decision Support and the use of registries. Care Coordination is further enabled through EHR interconnectivity, breaking down silos between primary and specialty care, as well as care received in different settings. This gives providers much more ability to collect and maintain a comprehensive patient record, thereby knowing their patients better.

A higher level area identified in the value study as warranting further research is the disconnect between personal levels of satisfaction with care received/delivered and the vote for quality at a national level, as shown in the graphic below.

Though the three stakeholder groups surveyed don’t believe health care quality in the U.S. is the best in the world, 80% or more of each stakeholder group are satisfied with the quality of care received or delivered. This implies that, though we are highly satisfied with our care, we believe that, globally, better care exists.

Where do we go from here?

Though we may never fully remedy the misalignment of what is deemed most valuable across stakeholders, being mindful that perceptions vary is critical to creating an environment that is perhaps more responsive to value-based care and where all stakeholders feel vested.

We must find ways to monitor not only perceptions of value, but also changes across this continuum, to ensure that we aren’t pursuing value that only appeals to insurers, employers, or hospitals. Generally speaking, it can be challenging to satisfy a society groomed to expect instant gratification, but considering what’s important to another is a worthwhile place to start.