Value-Based Medicine

Human Value is Highest Treatment Priority

By Melissa M. Brown, MD, MN, MBA

As I expect you've heard, on March 23, 2010, President Obama signed the 2,300-page Patient Protection and Affordable Care Act, a comprehensive healthcare reform bill. It's been a hot item of conversation in many conference halls, TV and radio talk shows, board meetings, physicians' offices and neighborhood taverns—it even reaches our kitchen tables. One of the mandates of the law is to establish a nonprofit Patient-Centered Outcomes Research Institute to identify research priorities and conduct research that measures the comparative effectiveness (the methodologies for which are unspecified) of medical treatments. The Institute will be overseen by an appointed Board of Governors from both the private and public sectors.

The broad mandate has been set forth for the organization, and monies have been slotted for initial research to the National Institutes of Health, the Agency for Healthcare Research and Quality, and the Department of Health and Human Services. Nonetheless, these funds seem to have been distributed without an overriding vision for comparing all interventions using a common instrument.

We will examine some of those specifics in a future column, but it remains clear that the Value-Based Medicine principles to develop information systems detailing comparative effectiveness analyses and priorities are already present and accounted for.

Zeroing in on Standardization

The absolute need for standardization of research methodology is also well known, but hardly well established. We have mentioned various numerical guidelines used throughout the world to define cost effectiveness, but for today, let's use $50,000/QALY (quality-adjusted life-year) as the level below which interventions are deemed very cost effective and $100,000/ QALY as the cutoff above which they are not cost effective.

When looking at these numbers, it is helpful to remind ourselves that an expensive therapy will be cost effective if it delivers high human value (i.e., improvement in quality of life and/or length of life) to patients. Conversely, an inexpensive therapy may not be cost effective, or perhaps not as cost effective as one might expect, if it offers little human value to patients.

Human Value vs. Financial Value

My colleagues and I continue to highlight the principle that every patient deserves the intervention that delivers the greatest human value. In essence, human value trumps cost. We assert that physicians, insurers, hospitals and those who allocate medical resources should do everything possible to maximize the human value delivered to patients.

However, as is often the case, where there are two or more interventions that confer similar human value, it is incumbent upon us and our healthcare systems to consider the best financial value and enable cost savings. And there are and will be many opportunities for this. We estimate that well over $150 billion annually could be saved from our healthcare system if Value-Based Medicine principles were adopted. At the same time, the highest possible quality care would be delivered.

Effectiveness Measures

Table 1 looks at comparative effectiveness, measured in QALY gain format and percent gain in human value, and cost utility (cost effectiveness) ratios numbers for interventions with which we are all familiar. Note that initial cataract surgery and cataract surgery in the second eye deliver considerable human value and are very cost-effective.

We should continue to become acquainted with these types of comparisons and continue to increase our knowledge of the best methodology for comparative and cost effectiveness. The Patient Protection and Affordable Care Act will only protect and care for us if we get it done right. OM

Value-Based Medicine is a registered trademark of the Center for Value-Based Medicine.

Melissa M. Brown, MD, MN, MBA, is president and CEO of the Center for Value-Based Medicine in Philadelphia. She can be reached via e-mail at mbrown@valuebasedmedicine.com.