Value-Based Medicine

The Human Value Gain: Spread the News

By Melissa M. Brown, MD, MN, MBA

There are two types of value gains in Value-Based Medicine. The first is the human value gain, or the improvement in quality of life and/or length of life gained from an intervention, while the second is financial value gain, or a reasonable price paid for the human value gain. In this column, we address human value gain. More and more, those who allocate healthcare dollars are looking at the human value conferred by interventions. For ophthalmology, the great majority of interventions convey human value gain by improving quality of life. To the uninitiated, length-of-life gain may be more impressive, but those with serious illnesses very much appreciate quality of life.

Quantifying QOL

The instrument most often used to measure QOL is Short Form-36 (SF-36). Unfortunately, this instrument is not especially sensitive to ophthalmic diseases. While the National Eye Institute Visual Function Quotient-25 questionnaire (NEI-VFQ 25), the most commonly used ophthalmic instrument, is sensitive to vision in the better-seeing eye, it is not applicable outside of ophthalmic diseases. Neither the SF-36 nor the NEI-VFQ 25 value ophthalmic interventions to the degree that time tradeoff utilities do with Value-Based Medicine analyses.

The more we can demonstrate that ophthalmic interventions are valued by patients, the greater will be: (1) our ability to deliver these critical interventions to patients and positively change their lives, (2) the guarantee of the prestige and importance of ophthalmic care in the medical and societal realms, and (3) the financial well-being of patients and our specialty.

Undervaluation is Typical

Working with a group from the Center for Value-Based Medicine (CVBM), this author and others¹ demonstrated that ophthalmologists underestimated the diminution of quality-of-life associated with macular degeneration by 96% for severe vision loss (< 20/200) and 750% for mild vision loss (20/20 to 20/40) compared to actual patients with AMD. The same is true for other ophthalmic entities, since we know that ophthalmic quality of life is related more to the degree of vision loss in the better-seeing eye, rather than the underlying disease entity.

How do different evaluators compare to patient results when assessing the QOL gain associated with ophthalmic conditions that cause vision loss? Terribly! Another CVBM study addressing the perceptions of different cohorts on quality of life associated with legal blindness (<20/200 OU) was undertaken. Remember that ophthalmic utilities based upon vision range from 0.00 (death) to 1.00 (20/20 vision OU permanently). Stein and colleagues ² noted the gold standard, or the mean patient utility for legal blindness, was 0.47, while that for ophthalmologists given the same scenario was 0.73, for non-ophthalmic medical clinicians was 0.82, and for the general community was 0.86. Ophthalmologists again underestimated the patient decrease in QOL by 96%, other physicians by 194% and the general public by 279%!

The numbers are astounding. They indicate that ophthalmologists greatly undervalue the considerable patient gain in QOL that accompanies our interventions, but that non-ophthalmic physicians and the general public undervalue the improvement in QOL to an even greater extent. These are the numbers supporting why our interventions are so critically important. They allow people: (1) to remain productive in the workforce, (2) to obtain and hold better jobs, (3) to stay in their homes, (4) to retain their independence by driving, (5) preserve their dignity by reading their own mail, handling their own finances, etc., and (6) take better care of their medical problems without help. This is a wonderful opportunity to spread the word, especially since we are armed with information about our interventions that other specialties generally lack.

Go Forth and Disseminate!

How do we share this evidence about the importance of our ophthalmic interventions? Educate our policymakers in Congressional committees if you have the opportunity to testify on ophthalmology. Inform your local federal and state politicians.

It's also a good idea for us to send peer-reviewed articles demonstrating the incredible quality-of-life gains of our interventions to the Coverage & Analysis group at CMS, and the AMA/Specialty Society Relative Value Scale Update Committee (also known as the RUC) that in forms Medicare on the work values and practice expenses for physician services in the Medicare Fee Schedule arena.

Send the information to local insurers (forward to the Medical Director and include a relevant article as an FYI), to the Agency for Healthcare Research and Quality, and to other docs. Write an article or letter to the editor for your local newspaper, go on the local (or national) radio and television stations, put peer-reviewed articles in your waiting room, share the evidence by interpersonal interactions. A story about a dramatic change in a single (unnamed) patient's life is the single most effective manner.

Regaining lost vision is critical. Cataract surgery provides a 20.8% gain in quality of life (human value gain). Other directly comparable interventions include: treating systemic arterial hypertension (6-9%), osteoporosis therapy (1-2%), prostatic hyperplasia therapy (1-2%), and the list goes on. Ophthalmic clinicians do wonderful things for our patients, no doubt about that. But few people know! And if we don't pass on the good news, who will?

Next month, we can look at the considerable financial resources that ophthalmic interventions deliver to patients and society, which are far greater than the costs of the interventions themselves. OM

References

1. Brown MM, Brown GC, Stein JD, Roth Z, Campanella J, Beauchamp GR. Age-related macular degeneration: economic burden and valuebased medicine analysis. Cam J Ophthalmol. 2005;40: 3:279-287.
2. Stein JD, Brown MM, Brown GC, Hollands H, Sharma S. Quality of life with macular degeneration. Br. J. Ophthalmol. 2003;87;8-12

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