Concepts for Evaluating High-Value, Cost-Conscious Healthcare
Healthcare costs in the U.S. are rising unsustainably, and further efforts to control costs are both inevitable and essential. Whether an intervention provides high value depends on an assessment of whether its health benefits justify the costs. High-cost interventions may provide good value because they are highly beneficial; conversely, low-cost interventions may be of little or no value if they provide little benefit. This article discusses three key concepts for understanding how to assess the value of healthcare interventions: 1) assessing the benefits, harms, and costs; 2) identifying the cost of the intervention as well as any potential downstream costs that will occur as a result of performing the intervention; and 3) estimating the incremental cost-effectiveness ratio.
- Comparative effectiveness research (CER) can provide the foundation for understanding whether an intervention can provide high-value care by assessing its benefits and harms. For example, does medical therapy or revascularization provide better outcomes for patients with ischemic heart disease? If CER also assesses utilization and costs, it can further provide a foundation for cost-effectiveness analysis.
- When considering the total cost of a healthcare intervention, downstream costs also should be examined. For example, diagnostic imaging can lead to additional costs from invasive procedures, while HIV screening can result in treatment costs for individuals that test postive. Moreover, there may also be downstream benefits and harms, e.g., PSA screening for prostate cancer can result in an intervention that might cause harm.
- When one intervention is both more effective and more costly, estimating the incremental cost-effectiveness ratio can help determine if the intervention is worth the additional expense. In other words, will the intervention provide high-value care? The incremental cost-effectiveness ratio denotes how much additional money is required to gain additional health benefit when clinicians move from a strategy that is less effective to a strategy that is more effective.
- The authors suggest that the first step toward providing high-value healthcare is to reduce or eliminate the use of interventions that provide no benefit. Routine, rather than selective, imaging for low-back pain is one example. A second step is to ensure that we provide interventions that are both effective and reduce costs. The use of warfarin in high-risk patients who have non-valvular atrial fibrillation is an example. Finally, for interventions that provide additional benefit at additional cost, cost-effectiveness analysis is recommended, but should not be the sole determinant of use.
- The successful delivery of high-value care will depend greatly on the development of evidence to help understand which services provide good healthcare value, and on the engagement of clinicians, policymakers, and patients in efforts to promote high-value care.
Dr. Owens is part of HSR&D’s Center for Health Care Evaluation in Palo Alto, CA; Dr. Shekelle is part of the VA Greater Los Angeles Healthcare System.
Owens DK, Qaseem A, Chou R, and Shekelle P. High-Value, Cost-Conscious Health Care: Concepts for Clinicians to Evaluate Benefits, Harms, and Costs of Medical Interventions. Annals of Internal Medicine February 1, 2011;154(3):174-80.