VALUE-BASED TREATMENT AND OUTCOMES

Value-based treatment and outcomes is a largely discussed topic in national healthcare today. Unfortunately though, there is not a unanimous definition of “value” within traumatic brain injury (TBI) rehabilitation.

The value-based treatment and outcomes model promotes the most effective and results driven practices to be implemented in the most cost-effective ways available. Value is the perceived benefit to a patient’s health, as determined by the difference created from the inverse relationship between better treatments and lower costs.

The greater the difference, the greater the value. By this logic, a person would determine the value of a new clothing item not only by the article’s look, fit, durability, etc., but also by accumulating those benefits and weighing them in comparison to the cost of the item.

I argue that the term “value” in value-based treatment and outcomes ought to refer to the value received by the patient, and less so, perhaps, by the payer.

In this example, the purchaser is also the person ascribing perceived value to the purchase, whereas the party paying for a healthcare service is rarely the party receiving the service. It is in this divide between the paying party and the receiving party where the perception of value often varies.

In healthcare, value to the paying party may be defined as a need to meet the contractual obligation of coverage in the most cost-effective manner possible. Reiterating value-based treatment and outcomes, the two components necessary are the most effective care and the most cost-effective means.

Simply meeting the contractual obligation of coverage, however, is not always sufficient to the provision of most effective care, and many times this approach unfortunately reduces the discussion of treatment to that of costs involved, thus limiting the duration of TBI residential programs and rehabilitation treatments.

The transition of health insurance from nonprofit to for-profit and the need to continually satisfy shareholders’ financial expectations can stand in tension to the need to provide the most effective care, especially if that care seems more costly. Furthermore, the tremendous complexity of acquired brain injury is unrivaled by any other medical diagnosis. This complexity is rarely understood by health plan professionals whose job is to review benefits and coverage and approve an individual’s treatment, resulting in cost-based decision making over efficacy-based decision-making. 

On the other hand, the value of the same services to the person receiving them may place a greater level of importance on most effective care. For example, while being able to ambulate with a normal gait and endurance may be of great value to the patient, the payer may want to forego costs necessary for such an end result and instead settle for the patient’s ability to ambulate with less efficiency and for very simple purposes, i.e., short distances or with supervision. 

I argue that the term “value” in value-based treatment and outcomes ought to refer to the value received by the patient, and less so, perhaps, by the payer. Do individuals with TBI ascribe the highest value to a “functional” outcome, or to an outcome that represents the maximization of their post-injury ability? Is “functional” the highest value outcome, and if, so, for whom? 

That the payer may find relatively little motivation and, therefore, value in paying for the most effective service available is, unfortunately, disconnected from the values of the person needing or receiving the services. And, that the patient may not be aware of all that they should be about treatment choices, treatment efficacy, and prognosis, leaves patients remarkably vulnerable to treaters, payers and others.

This disconnect serves as a disquieting confound to the value-based treatment and outcomes model in healthcare. The value intended to result from a difference between most-effective care and the most cost-effective means is diminished to a value found only through the latter half of the equation, cost-effectiveness.

Given the strikingly different definitions of value between a payer and a patient, the issue can be ethically challenging and quite pointed. Ultimately, the obligation for all parties should be to the value-based treatment and outcomes model, and this model should not be jeopardized.