As I walk into the well-upholstered elevator lobby of the hospital and make my way toward the stairs for another night of covering the ICU, I am again inundated with plaques, advertisements and a six-foot-tall cardboard cutout depicting an executive in a suit reminding us that this hospital is among the best in the nation in providing “value.” As I was previously made aware during a resident education session sandwiched between our morbidity and mortality conference and oral board preparation, value in the hospital context is defined as quality divided by cost, with the obvious goal of improving quality while decreasing cost — thereby maximizing the value of health care provided.
Distracting myself from the thought of an ICU full of sick patients awaiting just two flights of stairs above my head with no sleep in sight for many more hours — I pondered how disparate and unhelpful the terms value, quality and cost (terms originating from the business realm and increasingly applied to hospitals nationwide) are depending on context and perspective. I deliberated what the acceptable quality-to-cost ratio is according to hospital administrators, insurance providers, uninsured versus insured patients and physicians.
What is the correct QALYs per U.S. dollar that I should provide while delivering care? It’s quite easy to imagine the ideal scenario of minimizing costs while maintaining the current quality in order to achieve a net increase in value. But what about drastically cutting costs and experiencing only a small decrease in quality? Wouldn’t that also increase the value we provide (albeit to the detriment of some patients)? How about hepatitis C antiviral medications or CAR-T therapy which have astronomical costs but have the potential to dramatically alter patients disease course and improve their quality of life — how are those valued?
Furthermore, what about my training? As a general surgery resident, I very much value the opportunity to perform operative cases under a senior surgeon’s supervision. However, doing so necessarily increases the length of operations and therefore overall cost of delivering care. By definition, decreasing the value, according to the equation.
Maybe I am being cynical and overly literal in my elucidation and application of value as it is applied to hospitals and physicians. Certainly, becoming aware of health care costs as it relates to decisions regarding tests, medications, operations, and utilization of equipment while maintaining high-quality standards should be encouraged and rewarded. However, as I enter the ICU knowing I will emerge 13 or so hours later feeling tired and hungry, I realize I value my time perhaps more than anything. The time I have to interact with my patients, the time in residency I am afforded to learn from my superiors and become a proficient surgeon and the limited amount of quality time I have to spend with my family outside the confines of the hospital. I know my patients waiting in the ICU have their own set of values, while the hospital administration has another.
Physicians will not escape application of the value ratio — and, indeed, we should not attempt to do so. Physicians are in a unique position to advocate for our patients’ values as well as our own; to emphasize that quality is more than laborious documentation designed to meet billing and data metrics, and ultimately reinforce historical ideals of placing the patient first and respecting the individual patient-physician relationship.
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