Definition

Providing patients with the best care at lower costs; often defined by quality divided by costs. The consideration of value should include outcomes (or quality of care), patient experience, and costs.

• High-value care reduces unnecessary costs to the healthcare system. A percentage of healthcare costs is considered “waste.”
• There are multiple categories of waste including unnecessary services, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse, The largest contributor to this “waste” is “unnecessary services,” which includes overuse (interventions provided beyond evidence-established levels), discretionary use beyond benchmarks, and unnecessary choice of higher-cost services.
• As hospitalists, we are responsible for ensuring high-value care to reduce unnecessary costs to the healthcare system mainly by deciding which diagnostic tests and therapeutic interventions to order.

Providing High-Value Care

Recommendations to ensure the provision of high-value care:

• Decrease or discontinue interventions with no benefit (e.g. use selective rather that routine imaging for low back pain).
• Increase interventions with high value (e.g. ensure compliance with aspirin for patients post myocardial infarction or ischemic stroke).
• The Choosing Wisely campaign includes specialty-specific evidence-based recommendations for avoiding low-value services, available at www.choosingwisely.org.
• For interventions that provide benefit at an additional cost, assess the value to the patient and society with cost-effectiveness analyses, understanding that the cost of an intervention includes downstream physical and financial costs.

Costs of Commonly Ordered Diagnostic Tests at Moffitt-Long Hospital

While an in-depth review of cost-effectiveness analysis is beyond the scope of this chapter, it is important for hospitalists to at least be cognizant of the relative costs of the tests that they are ordering. The following is a list of common hospital costs:

Data abstracted from 2014, obtained from the following websites. Based on inpatient charges.

http://www.oshpd.ca.gov/chargemaster/default.aspx

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/clinlab.html

The UCSF Clinical Laboratories maintain an on-line laboratory manual that is constantly updated

http://labmed.ucsf.edu/labman/.  Contains important information regarding test availability and turnaround time and test utilization tips.

Donald M. Berwick, MD, MPP; et. al. Eliminating Waste in US Health Care. JAMA. 2012;307(14):1513-1516.

Douglas K. Owens, MD, MS; et. al., for the Clinical Guidelines Committee of the American College of Physicians. High-Value, Cost-Conscious Health Care: Concepts for Clinicians to Evaluate the Benefits, Harms, and Costs of Medical Interventions. (2011). Annals of Internal Medicine. Vol 154, No. 3.

Hamill, Tim (2010). “Lab Test Utilization: The right, the wrong, and the overused” [PowerPoint slides]. Retrieved from http://medschool.ucsf.edu/gme/GRounds/GR%202010/092110.html. UCSF Billing Department

Moriates C, Arora V, Shah N. Understanding Value-Based Care. McGraw-Hill 2015.

Porter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Boston: Harvard Business School Press, 2006