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What Is Value in Health Care? — NEJM

Christine M. Veenstra, Andrew J. Epstein, Kaijun Liao, Jennifer J. Griggs, Craig E. Pollack, Katrina Armstrong. . (2015) Hospital Academic Status and Value of Care for Nonmetastatic Colon Cancer. 11:3, e304-e312.

Aslam Ejaz, Yuhree Kim, Gaya Spolverato, Ryan Taylor, John Hundt, Timothy M. Pawlik. . (2015) Understanding drivers of hospital charge variation for episodes of care among patients undergoing hepatopancreatobiliary surgery. 17:11, 955-963.

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Much of the total cost of caring for a patient involves shared resources, such as physicians, staff, facilities, and equipment. To measure true costs, shared resource costs must be attributed to individual patients on the basis of actual resource use for their care, not averages. The large cost differences among medical conditions, and among patients with the same medical condition, reveal additional opportunities for cost reduction. (Further aspects of cost measurement and reduction are discussed in the framework paper “Value in Health Care.”)

Roy Xiao, Jacob A. Miller, William J. Zafirau, Eiran Z. Gorodeski, James B. Young. . (2017) Impact of Home Health Care on Healthcare Resource Utilization Following Hospital Discharge: a Cohort Study. .

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The current organizational structure and information systems of health care delivery make it challenging to measure (and deliver) value. Thus, most providers fail to do so. Providers tend to measure only what they directly control in a particular intervention and what is easily measured, rather than what matters for outcomes. For example, current measures cover a single department (too narrow to be relevant to patients) or outcomes for a whole hospital, such as infection rates (too broad to be relevant to patients). Or they measure what is billed, even though current reimbursement practices are misaligned with value. Similarly, costs are measured for departments or billing units rather than for the full care cycle over which value is determined. Faulty organizational structure also helps explain why physicians fail to accept joint responsibility for outcomes, blaming lack of control over “outside” actors involved in care (even those in the same hospital) and patients' compliance.

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To assess the effect of OA implementation at 1 year on: (1) diabetes care processes (testing for A1c, LDL, and urine microalbumin), (2) intermediate outcomes of diabetes care (SBP, A1c, and LDL level), and (3) health-care utilization (ED visits, hospitalization, and outpatient visits).

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Achieving high value for patients must become the overarching goal of health care delivery, with value defined as the health outcomes achieved per dollar spent. This goal is what matters for patients and unites the interests of all actors in the system. If value improves, patients, payers, providers, and suppliers can all benefit while the economic sustainability of the health care system increases.

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Health care delivery involves numerous organizational units, ranging from hospitals to physicians' practices to units providing single services, but none of these reflect the boundaries within which value is truly created. The proper unit for measuring value should encompass all services or activities that jointly determine success in meeting a set of patient needs. These needs are determined by the patient's medical condition, defined as an interrelated set of medical circumstances that are best addressed in an integrated way. The definition of a medical condition includes the most common associated conditions — meaning that care for diabetes, for example, must integrate care for conditions such as hypertension, renal disease, retinal disease, and vascular disease and that value should be measured for everything included in that care.

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Accountability for value should be shared among the providers involved. Thus, rather than “focused factories” concentrating on narrow groups of interventions, we need integrated practice units that are accountable for the total care for a medical condition and its complications.

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CHRISTOPH PROSS, ALEXANDER GEISSLER, REINHARD BUSSE. . (2017) Measuring, Reporting, and Rewarding Quality of Care in 5 Nations: 5 Policy Levers to Enhance Hospital Quality Accountability. 95:1, 136-183.


Carey Kimmelstiel, Efthymios N. Deliargyris. . (2017) Bivalirudin versus heparin for peripheral vascular intervention: You get what you pay for…. 89:3, 414-415.

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