Medicine must be value-based

Paco Miralles

Many of us believe that medicine in general and doctors, in particular, should direct efforts to provide patients with value services. This approach would leave even the profane flabbergasted: but do doctors not do for their patients that which gives them value?

It's important to know the past to understand the present and outline the future. For a few decades, we have acted based on evidence-based medicine, a movement that led to the transition to a methodologically neater practice. Assistance based on tradition and empirical experience would succumb in the face of well-structured studies. This revolutionary concept led him to be nominated as one of the ideas of the year 2001 by The New York Times.



For years this movement has shaped the thoughts of students and clinicians. This methodology based on tests and large trials has brought a lot of light. In return, we have paid prices as the limitation of clinical reasoning. With the best evidence, clinical guidelines have been built in which a large majority of patients are not represented. Hence, we plan these recommendations in our patients by "approximation" and generate many ineffective actions.

A new paradigm tries to impose itself, although slowly, on the healthcare environment: medicine that adds value. It consists of integrating not only the best scientific evidence but the patient's needs and preferences. More and more publications support this way of acting in professionals. However, it has not just entered the health institutions. On many occasions, you are left with just a good marketing slogan or newspaper tag line.

Many scientific societies support international initiatives such as Choosing Wisely that aim to reduce overdiagnosis and overtreatment. In our country, platforms such as Dianasalud seek the dissemination of initiatives in analysing the adequacy of specific health actions. The blog created by Jordi Varela has become a reference point of opinion in value-based medicine. But even though many references are emerging to support this new healthcare movement, the most conclusive proof of the interest it is raising, is that numerous insurance companies in the United States and Medicare link part of the payment to their providers based on responsible care.

An article has recently been published in JAMA that analyzes the variability of primary care physicians in the provision of acts of low value. One of the conclusions is more than obvious: none of the clinicians was exempt from having performed any improvable performance, or in simple terms, even the best scribe uses an eraser.

My reflection after reading this article led me to consider that most of the work focuses on the actions of clinicians and not so many, although some are those that analyze health organizations. It's obvious that the final accountability for the prescription is the doctor, but will this not be the weakest link in the chain?

In our country, it does not seem that healthcare providers, both public and private, are busy looking for valuable actions in patients. Public hospitals have enough to meet the rising demand for care activity, demand that grows on many occasions due to lack of social awareness. It seems written in the human subconscious that more medicine means better health. Those of us who work in this sector know that this isn't always the case (I recommend the magnificent reflection on this in this post). Hence, different initiatives have emerged that aim to dismantle this axiom based on scientific data, two good examples being "Less is more" from JAMA and "Too much medicine" from BMJ. The use of more medicine leads to more errors and a palpable sign of this is that these are the third cause of death in the western world.

Private hospitals also have other interests however legitimate. They provide assistance coverage to a large segment of the population that would be unassuming in the public system. Mostly they don't advocate the importance of actions focused on added value. On many occasions, they are criticized for increasing the recruitment of patients by offering techniques and/or technology that have not always shown added value in the health process.

On the other hand, the public and private assistance funders also decline to take decisive steps in the payment for the added value that could be the trigger a change in the system. The savings to be made by not paying dispensable actions, approximately 40% of what we do according to Vinay Prasard, would increase the investment in health and the improvement of staff fees.

It seems that both providers and funders deny functions in the training of the professionals who eventually will go on to later make clinical decisions. These people, in most cases, have to make their training plan and seek funding for courses that don't always advocate actions based on added value.

It is therefore paradoxical that only clinicians be put in the spotlight when requesting responsible actions; especially when, thanks to their professionalism, movements that promote banishing actions lacking scientific credit arise; but these can hardly be institutionalized.

If we want this new paradigm to succeed, we should ask ourselves not only what the clinician does but what health stakeholders do. Some measures could be:

• A commitment of healthcare providers to define the value practices that must be implemented;
• The condition part of the financing based on value practices;
• Information transparency in healthcare results; Not only what is spent is important but what results it generates.
• Independent and proven knowledge that supports the comparison.
• Facilitate the training of professionals by their institutions so that the best evidence can be integrated with the ability to recognize biases and decision-making shared with the patient.
• Economic incentives are available to professionals for their development.

If there’s no involvement of suppliers and payers, we‘ll continue to put the objective in the weakest link in the chain. In plain language, all the birds eat wheat but the sparrow takes the most blame.

Link to blog Doctor Miralles