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Journal of Multidisciplinary Healthcare 2017:10 101–106
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P E R S P E C T I V E S
open access to scientific and medical research
Open Access Full Text Article
http:
dx.doi.org/10.2147/JMDH.S122383
Value as the key concept in the health care
system: how it has influenced medical practice
and clinical decision-making processes
Chiara Marzorati1,2
Ga
iella Pravettoni2,3
1Foundations of the Life Sciences,
Bioethics and Cognitive Science,
European School of Molecular
Medicine (SEMM), 2Applied
Research Division for Cognitive and
Psychological Science, European
Institute of Oncology, 3Department
of Oncology and Hemato-Oncology,
University of Milan, Milan, Italy
Abstract: In the last 10 years, value has played a key role in the health care system. In this
concept, innovations in medical practice and the increasing importance of patient centeredness
have contributed to draw the attention of the medical community. Nonetheless, a large consensus
on the meaning of “value” is still lacking: patients, physicians, policy makers, and other health
care professionals have different ideas on which component of value may play a prominent
ole. Yet, shared clinical decision-making and patient empowerment have been recognized as
fundamental features of the concept of value. Different paradigms of health care system em
ace
different meanings of value, and the absence of common and widely accepted definition does not
help to identify a unique model of care in health care system. Our aim is to provide an overview
of those paradigms that have considered value as a key theoretical concept and to investigate
how the presence of value can influence the medical practice. This article may contribute to
draw attention toward patients and propose a possible link between health care system based
on “value” and new paradigms such as patient-centered system (PCS), patient empowerment,
and P5 medicine, in order to create a predictive, personalized, preventive, participatory, and
psycho-cognitive model to treat patients. Indeed, patient empowerment, value-based system,
and P5 medicine seem to shed light on different aspects of a PCS, and this allows a better
understanding of people under care.
Keywords: health care system, value, value-based medicine, patient empowerment, clinical
decision-making, patient centeredness
Introduction
Nowadays, the concept of value is a prominent topical issue in health care. Individual
needs, wishes, preferences, and ethics influence the meaning of value which, in turn,
is influenced by different cultures or historical periods.1 The necessity of finding better
ways of redirecting the incentives away from volume and toward value pushes patients,
physicians, policy makers, and other stakeholders to turn their attention toward what
value means and what are the main features of this concept.2 Even if there is still no
unanimous agreement on value’s definition, it is commonly accepted that values in
health care may be defined as normative guidelines helping us to evaluate actions or
situations and influencing the decision-making process.3–5
Different studies point out how the definition of value changes according to the
eference sample: doctors’ values, most of the time, do not match the values of the
patients, and vice versa.3,6,7
The presence of different opinions encourages some reputable organizations and
associations to base their definitions of value on expert judgment or on empirical studies
Co
espondence: Chiara Marzorati
Foundations of Life Sciences, Bioethics
and Cognitive Sciences, European School
of Molecular Medicine, Via Adamello 16,
20139 Milan, Italy
Email XXXXXXXXXX
Journal name: Journal of Multidisciplinary Healthcare
Article Designation: PERSPECTIVES
Year: 2017
Volume: 10
Running head verso: Marzorati and Pravettoni
Running head recto: Value as the key concept in the health care system
DOI: http:
dx.doi.org/10.2147/JMDH.S122383
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Marzorati and Pravettoni
that co
elate attributes of value with a measurable outcome.
According to this, the American Heart Association (AHA)
underlines that, even though clinical efficacy and outcomes
constitute the primary basis of good medical practice, value
plays – together with costs – an important role, and it includes
positive results in patient’s outcome, safety, and satisfaction
at a total cost that is reasonable and affordable.6 However, in
2008, the Institute of Medicine7 (IOM) held a 2-day workshop
to explore key stakeholders’ perspectives on value in health
care, seeking to understand the meaning of value. Finding a
mutually acceptable agreement among the different points
of view, as expressed by patients, providers, economists,
payers, and employers, is understandably complex. In fact,
providers considered value on the basis of appropriateness of
care and effective, evidence-based interventions; economic
epresentatives defined value as the clinical benefit achieved
for the money spent. Patients, however, place their attention
on the ability of health care to satisfy their goals: a valuable
intervention is a way of treating that also fulfills their needs.8
Indeed, from a patient’s perspective, the burden of illness
is not limited to disease status, but it is also important to
consider quality of life (QoL) factors and, more precisely,
health-related QoL, refe
ing to its clinical dimension.
Patient’s needs are frequently measured taking into account
different aspects of QoL, such as pain, emotional and cog-
nitive functioning, or functional impairment.9,10 Moreover,
a recent review11 on patient’s perceptions of quality of care
emphasizes how communication, health care access, and
shared decision-making (SDM) are the key elements in a
valuable health care environment.
Nowadays, even if we na
ow our attention to the medi-
cal context, we are not able to identify the core features of a
health care system based on value because every paradigm
adopts different definitions of value. The absence of common
and widely accepted meaning allows each movement in health
care practice to take into account different components of
value identifying different model, of care. The aim of this
article is to provide an overview of the main approaches of the
last 10 years that have considered value as the key theoretical
concept. As we shall see, each movement adopts a particular
definition of value leading to a different application of these
paradigms in the health care system.
From evidence-based medicine (EBM)
toward value-based medicine (VBM)
Two decades ago, the EBM was the first movement in
health care that disregarded the paternalistic approach and
revolutionized the idea of doing science. The EBM intro-
duced a new way to make good clinical decisions: health care
decisions should be based on the best available evidence mixed
with the clinical expertise.12 External evidence and clinical
expertise must be integrated with patients’ preferences in
making medical decisions about their care; only in this way,
doctors will be able to identify the best interventions to maxi-
mize QoL of patients and minimize the cost of their care.13
Despite its success throughout the scientific world, some
esearchers have started asking whether this paradigm has
een facing a crisis. Among different reasons, Greenhalgh
et al14 suggested that, during the course of the years, EBM has
forgotten the importance of individualism. Evidence should
e understandable by all patients, practitioners, and other
stakeholders, and they should share discoveries and fears to
take reasonable decisions.14 At the same time, preferences,
wishes, thoughts, and all individual aspects of patients were
included in the conceptual label of value, becoming like a
constellation of principles with an important role in life. Fol-
lowing the definition of Sackett et al15 with “patient values
we mean the unique preferences, concerns and expectations
each patient
ings to a clinical encounter and which must
e integrated into clinical decisions if they are to serve the
patient.”
In the last 10 years, to re-emphasize the importance of
patients’ preferences and QoL, new paradigms were born,
turning their attention toward individual aspects and focus-
ing on patient’s value. Consequently, health care paradigms
faced a shift from EBM to VBM. The term “value-based”
was first introduced by Brown et al who defines this new
paradigm as “the practice of medicine incorporating the
highest level of evidence-based data with the patient per-
ceived value confe
ed by health care interventions for the
esources expended.”16
EBM focuses its attention on clinical trial results and uses
these data to provide the best care and, in the meanwhile, it
usually ignores the importance of QoL improvement. Instead,
the VBM leads to a higher level the discoveries of EBM cal-
culating the value of operations in medical practice, based
on pharmacoeconomic principles.1 The value is measured
objectively by calculating the improvement in QoL and life
expectancy after surgery: the result is the benefit derived from
an intervention for the costs expended.17,18 In other words,
VBM takes EBM to a higher level, including the QoL in the
data analysis and interpreted the data in relation to the value
and costs of an intervention. In so doing, VBM utilizes a
health care economic cost–utility analysis where results could
e interpreted in terms of $/QALY (quality-adjusted life
year), considering the dollars spent for the improvement in
length of life and/or QoL on a continuum from 0.0 (death) to
1.0 (perfect health).19 QALY is the arithmetic product of life
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Value as the key concept in the health care system
expectancy combined with the measurement of the quality
of remaining life years.20 The choice of the “right methodol-
ogy” had been controversial, and they finally opted for a time
trade-off cost–utility analysis since it would be applicable in
any specialty of medicine, allowing a comparison across dif-
ferent interventions.18