It has often been said that “value is in the eyes of the beholder.” Michael Porter, professor at Harvard Business School, introduced the concept of Value-Based Health care. He defined value in health care as:
“the measured improvement in a person’s health outcomes for the cost of achieving that improvement”
This needs to be considered in the broadest context, through a holistic, multi-disciplinary approach to the delivery of healthcare. It’s not just the treatment of disease but encompasses improving patients’ overall health and reducing the incidence and effects of chronic disease. Ultimately, providers are rewarded for helping patients live healthier lives.
As seen through the patient lens,
VALUEPatient = (HEALTH OUTCOMESPatient) / (COSTPatient)
But the patient ‘cost’ is really the patient burden, so
VALUEPatient = (HEALTH OUTCOMESPatient) / (BURDENPatient)
…where patient burden consists of physical burden, emotional (or pyscho-social) burden, financial/cost burden and time/effort burden.
What can be done to increase the value from the patient perspective? Simple math indicates there are two ways to enhance patient value – by either increasing the numerator (Health Outcomes) and/or reducing the denominator (Burden). Both levers must be considered and pursued.
How can people improve their health outcomes?
- Better Wellness Care can lead to a happier, healthier, more productive life – eating a balanced diet, regular exercise, sufficient sleep every night, keeping mentally active are all important elements of preventive care;
- Better Access to Treatment for all – As witnessed during the Covid pandemic, disparity in access to quality healthcare is a significant issue confronting society. Without access, underserved communities will continually struggle to improve their health outcomes.
At a macro/societal level, both the WHO (World Health Organization) and CDC (Center for Disease Control and prevention) consider the Social Determinants of Health (SDOH) primarily responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries. These determinants include:
- Healthcare access and quality
- Education access and quality
- Social and community context
- Economic stability
- Neighborhood and built environment
At the patient level, these socioeconomic barriers manifest in a variety of ways:
- Limited trust in medical professionals and the pharmaceutical industry
- Limited availability of proximate health clinics, neighborhood pharmacies and state-of-the-art treatment options
- Limited awareness and understanding of complex medical terminology, diagnoses, and treatment decisions
- Inadequate healthcare payer coverage
- Concerns with good housing, environmental considerations, quality food, and safety
- Limited access to broadband and other fundamental technologies.
Until these challenges are addressed, improving health outcomes in these underserved communities will lag, but there is a significant opportunity to greatly improve outcomes across a broad population by reaching out to these underserved in a more proactive manner.
- Early detection. The words ‘early detection’ are very empowering to patients. For cancer patients, it means having a fighting chance as there are likely more treatment options available than if the disease had been detected later. But how is this best achieved? Can it be achieved without creating additional anxieties and concerns? How can healthcare practitioners and health systems better enable early detection?
One obvious answer is that patients must act and fulfill their responsibility of seeking medical attention in a timely manner when things just don’t feel right. Many ignore the warning signs or just can’t make time in their busy schedules for a checkup or a test. It’s too inconvenient, and they fear what they may discover.
However, the healthcare landscape must be viewed through a different light. In the past, if a person lost her keys at night in a park, what did she do? Her initial instinct is to retrace her steps and look closely under the lampposts. Why? Because that’s where the light is, and she can actually see the ground.
There are many ‘early detection’ lampposts available throughout the park. Patients often provide family history as this can help healthcare practitioners identify people with a higher-than-usual chance of having a particular disorder, and with this early warning, doctors can initiate early intervention. Screening tests can be valuable tools in detecting potential issues via clear and simple results, particularly when performed at appropriate times as recommended by the healthcare provider. Many standard screening tests are embedded in mainstream healthcare:
- Cholesterol testing for cardiovascular disease;
- Pap smears for cervical cancer
- Diabetes screening
- Mammography for breast cancer
- Prostate Specific Antigen (PSA screening) for prostate cancer
- Colonoscopy for colon cancer and colon polyps
- Hearing and eyesight tests…
…and we readily search under these well-established lampposts. However, the world has moved on and the paradigms of yesterday are constantly challenged. If we lose our keys today in a dark park, we are not limited to only searching near lampposts. We carry our own light – the flashlights on our smartphones and this enables us to search anywhere, at any time. What are the newer ‘early detection points of light’ that are unleashed by technology?
Genetic testing is a powerful medical test that identifies changes in genes, chromosomes, or proteins. At a macro level there are several genealogy and family history research companies like AncestryDNA and 23andMe which help people trace their family history, but this is based on DNA testing and can serve as a risk screener for several genetic conditions and diseases. Using a cell-free DNA (cfDNA) test, the healthcare company Grail claims its early cancer detection product Galleri can detect fifty different types of cancer from a single blood draw. These tests can highlight predisposition to specific diseases. With this, individuals and their doctors could better track health around those ‘future risk diseases’ of that individual and stay aggressively ahead of it. This can be achieved relatively easily, though there are other patient burdens that could likely surface like anxiety of discovering that you have a predisposition to a disease in your future. Some patients are keen to have as much information as possible – if they know they have a predisposition for a particular disease, they can take steps to closely monitor or adopt a healthier lifestyle. However, some patients prefer not to know as many of these tests are not definitive and certainly can’t predict when a patient might be afflicted; they choose to deal with it when they must.
At the patient diagnosis level, results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person’s chance of developing or passing on a genetic disorder. For example, the Pancreatic Cancer Action Network (Pancan) started a program – “Know Your Tumor” – to understand the underlying biology of the tumor. Pancan encourages all pancreatic cancer patients to get genetic testing for inherited mutations as soon as possible after diagnosis and biomarker testing of their tumor tissue to help determine the best treatment options. The genetic makeup of the tumor can guide patients and their doctors to ‘better’ treatment options, which is known as precision medicine. Precision medicine leads to better health outcomes. In 2020, Pancan reported that patients with actionable alterations who were treated on ‘matched’ therapies had a survival of 2.58 years vs 1.51 years for patients who were not on matched therapies.
Technology affords even greater opportunities for early detection beyond testing. As an example, in an episode of the television show Billions, management provided their employees with a finger ring, which monitored some basic medical information continuously (for now, ignore the privacy issues that management was monitoring their employee’s health without their knowledge – a different topic). One of the senior managers was exercising on his stationary bike and an abnormality was detected by the ring and transmitted this information to the monitoring station. There was then a knock at the employee’s door by the paramedics saying that a person at this location was having a heart attack. Privacy aside, the burden on the subject was very low, but the benefit was enormous resulting in a significant value through pre-detection of a significant medical incident.
Finally, it is important to note an underlying patient benefit associated with clinical trial participation. By being closely monitored while participating on a clinical trial, patients are more likely to discover medical issues or complications more quickly. This form of early detection will lead to faster interventions by medical experts in the disease area. Companies should highlight this benefit to patients as part of its clinical trials documentation.
- Find an excellent doctor – Once patients receive a diagnosis of a disease, how do they choose a doctor? Is their primary physician trained in this disease? Is there anyone locally who has expertise in this disease and is current on the available treatment options? Obviously, this depends on the complexity of the disease diagnosis, but clearly overall health outcomes can be improved by having the best medical team. Most patients rely on their primary physician to serve as the Hogwarts ‘Sorting Hat’ – to match the patient with the ‘right’ specialist as required. Sometimes, however, the primary physician may not know or may be inclined to refer the patient to another doctor within their health system – a good doctor but maybe not the best doctor. Advocacy groups are a good source when looking for a disease specialist or finding leading physicians.. Ultimately, patients need to be comfortable selecting their medical team and seek advice from people they trust.
- Pursue the best treatment plan, whether it is standard of care or a clinical trial, to achieve the best health outcomes. This is not a trivial challenge for patients as they are often entering foreign territory. Usually, patients receiving a new diagnosis may have limited knowledge of the disease – what is it? How did I get it? What are the treatment options? Are there side effects, and if so, how impactful might they be? Will I be able to work? Can I afford this? And often, this information is presented in a technical morass.
The best treatment plan should be holistic and comprehensive. This is best achieved with a medical team that takes a multidisciplinary approach. For a cancer patient, the oncologist, radiation oncologist, surgeon, pain management, nutritionist need to consider the unique medical circumstance of each patient and develop an integrated ‘Personalized Treatment Plan.’ The full medical team must align to this common plan and coordinate its execution seamlessly. And just like a good financial plan, the Personalized Treatment Plan should be constantly adjusted as more data is obtained, everyone aligned to a common goal. Only then is it possible to achieve the best health outcomes for this patient.
Our ability to influence health outcomes has never been greater. Technology advances, both medical and non-medical, offer patients the opportunity to find and pursue treatment options that are better targeted to them as individuals. Improved health outcomes are attainable, however, the promise of better health wellness and precision medicine can only be fully attained if it is accessible, affordable, and available to all patients.
In part 2 of this article, we will take a closer look at patient burden and consider opportunities to increase patient value by reducing patient burden.