Amid ongoing health care transformation, clinicians will increasingly face the tension that the late physician and health services researcher John M. Eisenberg, MD, MACP, described over 30 years ago: providing high-value care with simultaneous commitments to patients and society.
Physicians have always been charged as patient agents to advocate for patients' best interests. Simultaneously, however, they are tasked with considering the societal good by using resources wisely. While these commitments often align in clinical care, as Dr. Eisenberg observed, they can sometimes conflict and create tradeoffs in clinical decision making. How should physicians act when patient good (e.g., desire for antibiotics for a viral illness) and social good (e.g., withholding antibiotics to prevent population-level resistance) are at odds?
The shift toward a value-based health system is poised to highlight these tradeoffs perhaps more than ever before. National campaigns and payment mechanisms are promoting clinicians' societal responsibilities by explicitly encouraging judicious, value-based resource utilization. At the same time, enabled by digital technology and marked by shared decision making, patient engagement, precision medicine, and patient satisfaction, the movement toward more patient-centered care conveys the need for physicians to provide tailored care that meets individual needs and values.
Clinicians can easily feel pulled in 2 directions by these seemingly disparate “value” messages. When caring for patients with uncomplicated, nonspecific lower back pain, for example, they are encouraged by high-value care initiatives (and, in some cases, local resource utilization policies) to avoid obtaining costly imaging studies. Yet patients not infrequently insist on imaging for reasons that provide personal value, reasons that are appropriate if viewed primarily through the lens of patient-centeredness, and that if ignored could also result in low patient satisfaction and negative reviews.
How can clinicians navigate these complexities and operationalize “value” in patient care? Some have argued that this should be a nonissue, that physicians should focus exclusively on patient needs, unfettered by financial considerations. With all physicians soon to be subject to value-based incentives, however, this is both unfeasible and undesirable.
A better alternative might begin by addressing how segments of the medical community have differentially conceptualized value. Some have been altogether skeptical, perceiving it as a Trojan horse for the cost-reduction strategies used in the managed care era of the 1990s. Others have approached it indirectly by concentrating on improving the quality of care. Noting the limitations of isolated cost reduction or quality improvement efforts, still others have codified value in terms of outcomes and quality relative to costs. More consensus can help advance the discourse about high-value care.
An additional step for limiting clinical tensions may be to move existing definitions forward by distinguishing between the average and marginal value of care. Expressed in economic terms as the “the incremental value achieved through additional output,” marginal value better approximates what patients and physicians experience in clinical encounters: decisions based on a patient's personal cost and benefit considerations that provide incremental benefit to that patient. In contrast, average value integrates the benefits and costs facing an entire group to promote high value for the majority. It forms the basis for ongoing high-value care initiatives, which encourage physicians to use population-level considerations in making clinical decisions.
Confounding these 2 kinds of value can cause confusion and impede progress, and differentiating between them is more than an exercise in labeling. Because populations can differ dramatically in terms of demographic, socioeconomic, and clinical determinants, clear distinctions can promote dialogue about how to meet specific group needs by balancing marginal and average value. Shared decision-making, for example, might support judicious utilization in some groups by correcting patients' disease misconceptions while encouraging more utilization in others by identifying outsized risk for downstream complications.
Distinguishing between the two can also help mitigate unintended consequences. As we are learning from other national health systems, applying value-based policies to clinical situations is not a one-size-fits-all proposition. Some areas are more ripe for reform than others, and definitional clarity can avoid confusion and highlight where well-intentioned policies might create inappropriate or unethical clinical tradeoffs.
Ultimately, the tension of balancing patient and societal commitments will always define clinical practice. However, ongoing health care transformation will test that dynamic by highlighting tradeoffs in ways that have historically, even by Dr. Eisenberg's own admission, often been too remote to affect patient care.
How clinicians will engage such changes depends in part on how we understand and evaluate different kinds of value in patient care. Clear definitional distinctions can help us achieve that end: providing the highest-value care possible in all senses of the word, with patients and society in mind.