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Letters to the Editor

In Reply to Daigle and Anand

Erath, Alexandra; Salwi, Sanjana; Sherry, Alexander MD

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doi: 10.1097/ACM.0000000000003773
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We thank Daigle and Anand for their thoughtful comments. In our Invited Commentary, we define high-value care (HVC) as “outcomes achieved per dollar spent.” The authors define HVC as outcomes mattering to patients divided by cost of care. In defining HVC with a broad, inclusive scope, we do not summarily dismiss the concept of patient-centered care or its value in education, as the authors imply. Rather, as patient-centered care is one of the National Academy of Medicine’s (NAM’s) (formerly the Institute of Medicine’s) 6 aims for the health care system,1 we believe this tenet to be central to improving health outcomes. In fact, we have designed an HVC course, which teaches patient-centered interviewing through simulations, ethics rotations, and didactics. Our broad definition of HVC can be analogously expanded to all NAM aims (e.g., cost-effective care that does not sacrifice safety or efficacy).

Additionally, we agree that establishing patient values is an essential component of HVC, but not because this informs a separate HVC definition. Rather, patient preferences contribute in part, but not in whole, to defining outcomes, and providing cost-conscious care can lower value if care does not achieve patient goals. We also recognize that patient-centric interviewing is commonly taught in medical schools, but that there is relative disparity in education on cost. Even with attention to patient health goals, ignoring the cost of care—the HVC denominator—can balloon spending and reduce the overall value achieved for patients. This concern is especially salient in the United States, where partial cost sharing is the norm for most forms of health insurance.

One cultural barrier to embracing HVC is the erroneous notion that HVC is at odds with patient-centered care. Some fear that awareness of costs must lessen focus on the patient. Rather, practical HVC simply allows providers to incorporate essential value information into their clinical decision making. Thus, incorporating HVC in terms of costs and inclusive, broadly defined health outcomes does not detract from the patient, but merely completes a holistic clinical picture.

Reference

1. Institute of Medicine (US) 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.
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