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For health care providers and payers, Value-Based Health Care (VBHC) is a hot topic, with most all payers pressing a shift toward financial risk contracts and ACOs based on quality and cost performance. But if you ask consumers about the trend, chances are you’ll get a blank stare. Why? They’re not really part of the conversation.
That’s a major problem, because consumer involvement is essential for VBHC success. When outcomes fall short, providers may complain about poor “patient compliance” with physician orders, and ACOs may bemoan lack of “patient engagement.” But they are minimizing patients’ preferences and concerns, or perhaps haven’t even bothered to assess what these are. Instead, they’re planning for their own desired results in savings, patient outcomes and revenues, without necessarily taking into account what patients feel they want or need.
How can VBHC work if patients can’t stick to treatment plans because they doubt their value? That’s hard to envision. Providers must understand what patients value, and convey choices in that context. Who can help them do that? Patients.
VBHC Needs Patients to Verbalize Goals and Choices
Both payers and providers purport to speak on behalf of patients or patient interests. But payers like Medicare and commercial insurers are the main architects of VBHC, with terms negotiated by providers. They are defining what care delivery models are constructed, how patients get that care, how quality is measured and how providers are paid.
Left unanswered is how consumers can get what they really want and need out of health care: improved function, freedom from pain and longer lives. Having the right partner (physician and care team) and committing to an improvement plan are the two essential ingredients. Talking honestly is the magic whisk.
Let’s be absolutely honest: Consumers do not have the tools to adequately navigate the health care system. Valid data and quality information for decision-making are essential. Patients need a range of knowledge, from whom they can trust to provide quality care to reliable facts about treatment benefits and risks. Finding this information independently is a real challenge; whatever data and research exists is largely sequestered from consumers.
We have suggested how consumers can choose providers without comparative quality data, by assessing physicians’ partnership value. In short, patients should seek providers who are willing to engage in a conversation about their health, goals, preferences and limits. But that choice is just the first step.
How do patients talk to their providers about their actual treatment options? First, the conversation needs to take place. While that seems like common sense, there are plenty of obstacles to clear.
Providers and Patients Don’t See Eye-to-Eye on the Health Care Relationship
Providers and consumers disagree over who is responsible for the patient’s health. A recent survey that questioned consumers, providers and employers about Value-Based Health Care highlighted those stark differences. While almost half of patients see health care as their personal responsibility, 75 percent of the providers who responded believe they are the ones responsible for their patients’ health. No wonder neither feels satisfied with the results!
The same survey revealed that both physicians and patients believe the cost of care is an important part of the treatment conversation. However, both parties often lack the information and training to enable that discussion—for example, knowledge about how to calculate that cost accurately—so it rarely takes place.
Given conflicting views on who is responsible for patient health and little discussion of costs, physicians trivialize patient decisions and judge their decisions by provider criteria. For example, the ability to pay or attend treatment is a real limitation for consumers, as illustrated by a recent study of patients who refused small cell lung cancer treatment. Unfortunately, yet not surprisingly, although the study identified patient rate of treatment refusal by various characteristics, no one collected data about the reasons the patients made their choices. However, “patients with Medicaid or no insurance consistently refused care no matter what the treatment.” Whatever their ability to pay, when faced with lower odds of successful treatment for lung cancer, patients confronting a similar choice may well determine that the value is not there, and decide to forego treatment.
No Time for Talk? How to Prepare Physicians and Consumers for Treatment Discussions
A 15- or even 30-minute office visit provides little time for information gathering, let alone a thoughtful discussion of alternative treatment options. Physicians are pressed for time by schedules, productivity incentives or just productivity measurement and practice culture.
But patients need facts in order to determine the value of treatment options, and physicians need to understand their patients’ barriers and circumstances before recommending those options. The best way to facilitate both objectives is for consumers to prepare for the visit.
In short, patients need to be assertive. For those who feel insecure about questioning their physicians due to lack of clinical expertise, rest assured that this isn’t about knowing medicine. It’s about learning to question the medical expert who also has access to medical knowledge and research, and determining what kind of certainty and risks they can live with.
Most patient visits to the doctor begin with presenting symptoms or pain. Tests or exams often follow, with results forming the basis for discussion of next steps and treatment options. Follow-up appointments are rarely a surprise and allow time for the patient to come prepared with questions. This is key, because the most expensive decisions rest on test results. This is also the time for physicians to prepare patients to understand conditions that will be confirmed or ruled out by testing. Providing ready-made materials to patients can be the first step in educating them about the risks of those specific conditions, so they can more knowledgeably converse when the results are in.
An essential preparatory step is for the patient to get test results as soon as they are available. This may violate the norm of some practices, since physicians want to explain this information to patients. But patients should insist anyway (and make this clear when the tests are ordered), because they will need time to read and process the information and plan their questions.
It doesn’t help either patient or physician to hold information for the next encounter in order to discuss both difficult test results as well as the condition and treatment options. This simply burns up time to more objectively review alternatives. The focus for both parties should be on the pros, cons and costs of next steps for interventions.
Weighing the Value of a Treatment Plan
For patients, the best strategy is to learn from their physicians as much as possible about the proposed treatment options and then get access to the data that will quantify the benefits and harms. That includes new information that is emerging about effectiveness and risks with long-standing procedures and medications.
It is “okay”—in fact, essential—to question physicians about what choices exist and what those mean to future health. The physician may see one perfect alternative, but that alternative may not work for the patient because of life circumstances. Personal circumstances affect the tradeoffs patients make and are part of the value equation.
Every treatment has both known benefits and harms that have been detailed in medical or clinical research, and patients should seek answers about these risks from their physicians. These benefits and harms should be quantified statements of value, such as percentages of success in disease eradication, or months and years of survival, and percentage of relapse or secondary disease.
Additionally, the physician recommending treatment should be able to demonstrate its effectiveness in current scientific research. This means physicians must keep abreast of major developments in their fields and be willing to investigate further on the patient’s behalf. Various surveys have revealed that this is a real challenge for clinicians to stay current in their own fields, given the vast numbers of clinical studies now published in hundreds of journals. Since all research is not equal—with biases, misinterpretations, and misapplications of results to individuals—it is all the more important for the patient to gain confidence in the effectiveness of a recommended treatment.
Basic Questions that Patients Should Ask Before Decisions
Let’s assume that the physician has already discussed the health status of the patient, provided details about the prognosis, and that the patient is ready for the next step—determining value and commitment to a plan of care.
When given treatment recommendations or choices, patients should ask questions that will provide the essential information for their decisions. At the same time, it is also important for patients to express their own limitations, goals and preferences, so that the physician understands and may modify recommendations. Here’s a starter list:
1. Why are you recommending this particular treatment?
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- What are its intended long-term effects?
- Can it fix my condition permanently? If not, what are the benefits?
- What are the side effects?
- Are there any possible long-term effects or future risks because of this regimen?
2. Would you show me research that demonstrates the benefits and risks of this treatment? Have there been any other studies that raise concerns about the treatment?
3. What alternatives to your recommendation are there? How do they compare in benefits and risks?
4. What is the cost of this treatment (also compared to alternatives)?
5. Can something else, such as changes in diet, activity or lifestyle, improve my condition without medical intervention?
6. What if I do nothing? Are there reasons why I need to take action immediately?
Value is Fluid—The Conversation Must Go On
Health status fluctuates over time. All patients experience physical issues that cause short or long-term impacts to their ability to function. Patients with high risk conditions that require ongoing care form a dynamic category; we may all eventually move into a high risk group as we age or develop impairments.
VBHC cannot eradicate patient risk, but it can help patients make choices of higher value. For both patients and providers, the talk is as important as the treatment.
Founded as ICLOPS in 2002, Roji Health Intelligence guides health care systems, providers and patients on the path to better health through Solutions that help providers improve their value and succeed in Risk. Roji Health Intelligence is a CMS Qualified Clinical Data Registry.
Image Credit: Luis Afonso Orellana