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Letters to the Editor

Rethinking the Cost of High-Value Care

Starr, Stephanie R. MD; Agrwal, Neera MD, PhD; Leep Hunderfund, Andrea N. MD, MPHE

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doi: 10.1097/ACM.0000000000002683
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To the Editor:

As medical educators, we strongly support Dr. Montori’s call to train health professionals in kind and careful care1—not as antithetical to value but, rather, as inseparable from it. Value, properly understood, highlights patient centeredness as a key dimension of quality2 and the burdens of treatment (for patients) and care delivery (for providers) as important aspects of cost. The error, then, lies not in pursuing value too far but in not pursuing it far enough.

An industrial definition of value prioritizes corporate profits, often at the expense of patients and providers. This ultimately undermines the “Quadruple Aim”3 to reduce costs while improving population health, patient experience, and provider well-being. This elegant synergy cannot be achieved by a reductionist view of value driven solely by economics.

Medical educators can be part of the solution by:

  • Introducing students to a nuanced understanding of value as quality (safe, timely, effective, efficient, equitable, and patient-centered care)2 divided by cost;
  • Encouraging students to examine value from multiple perspectives and consider how the interests of payers and providers could be aligned with patients’ interests;
  • Equipping students with practical, patient-centered communication skills for promoting value in clinical encounters (e.g., engaging in shared decision making or responding sensitively when patients request unnecessary interventions);4
  • Expanding “cost” to include not only out-of-pocket expenses but also nonfinancial burdens of treatment (for patients) and care delivery (for providers);
  • Creating opportunities for students to navigate the health care system with and for patients, sensitizing them to the work of “being a patient” and positioning them to bolster patient capacity and improve the system.

We can equip students to become change agents who see kind, careful care as high-value care, to recognize the shortcomings of industrial health care and respond with more sophisticated solutions.

Stephanie R. Starr, MD
Associate professor of pediatrics and director, Science of Health Care Delivery Education, Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota;
Neera Agrwal, MD, PhD
Assistant professor medicine and medical director, Mayo Clinic Quality Academy, Mayo Clinic, Phoenix, Arizona.
Andrea N. Leep Hunderfund, MD, MPHE
Assistant professor of neurology, Mayo Clinic, and associate director, Mayo Clinic Program in Professionalism and Values, Rochester, Minnesota.


1. Montori V. Turning away from industrial health care and toward careful and kind care. Acad Med. 2019;94:768770.
2. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001.Washington, DC: National Academies Press.
3. Bodenheimer T, Sinsky C. From triple to quadruple aim: Care of the patient requires care of the provider. Ann Fam Med. 2014;12:573576.
4. Natt N, Starr SR, Reed DA, Park YS, Dyrbye LN, Leep Hunderfund AN. High-value, cost-conscious communication skills in undergraduate medical education: Validity evidence for scores derived from two standardized patient scenarios. Simul Healthc. 2018;13:316323.
Copyright © 2019 by the Association of American Medical Colleges