Inconceivable! What Do We Value in High-Value Care?

This word, “value,” I do not think it means what we think it means.

A recent multicenter study published in Annals of Internal Medicine, triggered memories of one of my favorite childhood movies, The Princess Bride, in which a skeptical kidnapper claims that any suggestion or fact that threatens his own assertions is “inconceivable.” After many such denials, his less egomaniacal colleague eventually states, “This word. I do not think it means what you think it means.”

In the Annals study, researchers analyzed whether “augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk patients.” The goal of the study was to introduce a team-based care model to help stem the growth of overall health care spending. This focus on cost reduction aligns with that of other hospital systems and payers who have been trying similar tactics to achieve the same goal.

After randomly assigning patients to usual care or intensive management programs with interprofessional teams and care coordination, the researchers found that although inpatient hospitalizations and costs did trend down (without achieving statistical significance) in the intervention group, outpatient costs increased, resulting in similar mean total costs in the 2 groups. In discussions of health care value, it is easy to assume that the goal is to decrease overall cost, particularly given the well-publicized increases in health care costs in the United States. However, this intervention did NOT decrease cost at all and was still seen as valuable. Inconceivable!

I work within one of these VA interprofessional teams that assigns patients not just to a single physician but to a team including a patient, physician, nurse practitioner, social worker, pharmacist, nurse, administrative staff, and mental health specialist—in other words, a team capable of performing some of the interventions the authors proposed. Not only is their conclusion conceivable, but any practicing primary care team worth their salt knows this type of team-based care to be valuable. I personally think it is worth an incremental investment to make sure I have a pharmacist and a social worker and a mental health specialist at my fingertips every day—if it wasn’t more costly than usual care, I’d worry we weren’t paying them enough to work with our complex patients. So the real question is what we’re measuring when we make that inpatient-to-outpatient shift, and how much we’re willing to pay for it.

The authors themselves suggest that their approach to defining value may not fully capture the goals of patient care for the front-line patients and physicians on a day-to-day or even month-to-month basis. In the 12-month follow-up, the intervention showed no improvement in mortality. However, 1 year is not long when considering the benefits of outpatient preventive care. In ambulatory care, we play the long game, caring for acute issues but keeping our eye on the 10- and 20-year plans for our patients. Studies about primary care, many of which do not span that length of time, should be interpreted with the understanding that true benefits (in cost, health, and mortality) may not be seen for another few years. 

Meanwhile, most of us in ambulatory internal medicine know that intensive team-based care is what some patients need. We also know it’s not for everyone. In the Annals study, 37% of the patients randomly assigned to intensive management based on the complexity of their comorbidities did not complete it, often because their primary clinicians determined that those patients were not the ones who would benefit from the intervention. Leaning on their longitudinal patient relationships, primary care specialists can often tell who needs a little bit of extra help and who might not need it.

Doing the right thing may never be the cheapest option, and we should be willing to pay something to deliver care.  One of my patients the other day joked that the best thing for the system would be for me to let him continue his habits of drinking, smoking, and not taking his medications. He’s right. The cheapest medicine to practice is no medicine at all.

The questions that remain focus on paying how much and for what. Its approach for framing value notwithstanding, the Annals study suggests there may be value in incremental investments aimed at longer-term health outcomes that are not always measured in short-term, clinically based studies.

Lastly, in their analysis, the authors referenced previous studies of improved patient and provider experiences in intensive outpatient management programs, most of which were offered to patients who already proved themselves to be high utilizers of care. Meanwhile, our job as primary care specialists is to prevent any patients from getting that sick in the first place. We want to decrease hospitalizations not just for individuals but for entire populations. Such work will never be cheap. But it will often be right. And one day it may not be so inconceivable.

Reference

1. Yoon J, Chang E, Rubenstein LV, Park A, Zulman DM, Stockdale S, et al. Impact of primary care intensive management on high-risk veterans' costs and utilization: A randomized quality improvement trial. Ann Intern Med. 2018;168:846-54. [PMID: 29868706] doi:10.7326/M17-3039