Value extends beyond the cost of drugs and health care

By JENNIFER BRIGHT and MARK LINTHICUM

MARCH 14, 2019

In the ongoing debate about value in health care, the narrative in the media, political campaigns, and congressional hearings has consistently focused on the relatively narrow issue of drug pricing.

We are squandering time and resources trying to find a neat answer to “what is value?” by focusing on the cost of drugs without tackling other hard questions at the heart of measuring value across health care interventions.

Determining the value of health care requires understanding both its benefits and its costs — a complex undertaking that is sadly oversimplified in the public debate. Tellingly, Novartis CEO Vas Narasimhan said recently that one of the biggest things he has learned in the past year was how little understanding there is among the public about the concept of value versus the upfront price of drugs.

While the Institute for Clinical and Economic Review’s assessments that use cost per quality-adjusted life year have dramatically moved the ball forward on assessing the concept of value, a narrow focus on “right price” overlooks other essential elements of value, like worth, utility, and importance. The challenge arises in the complexity. Monetary value is an easy calculation, while worth, utility, and importance are more difficult to define, let alone quantify.

So how should health care decisions account for the more intrinsic attributes of value? By using fully transparent scientific approaches and a range of methodological tools that meet the diverse needs of all end users — patients, clinicians, employers, and others — to measure the worth of medicines and health care technologies.

As consumers are being asked to bear more responsibility for choosing and paying for health care services, it’s logical to assume they should be asked what they value. But they usually aren’t. As Centers for Medicare and Medicaid Services Administrator Seema Verma recently wrote in STAT, “Today, patients are essentially shut out of the process of defining value, when they should be at the center of it.”

Patient perspectives must be sought when assessing the value of a drug, a therapy sequence, a diagnostic test, or even a hospital service. Doing so unlocks a vital understanding regarding what is important to patients — including productivity, out-of-pocket spending, convenience, and the promise of hope, among many other concerns — that can and should be considered in calculating value.

There is growing consensus that incorporating sources of real-world data beyond effectiveness in clinical trials is important to understanding a treatment’s worth. Such data include health-related factors like real-world effectiveness, side effects, and impact on quality of life, as well as effects on caregivers, economic productivity, work restrictions, and broader medical costs. All of these must be considered when evaluating value.

Advanced methods to tailor value assessments to subgroups are also essential for illuminating our understanding of value. Relying only on population-wide estimates of clinical- and cost-effectiveness essentially assumes that everyone responds in similar ways to therapies, and we know that isn’t the case.

Advanced value assessment platforms, including those our organization is building, strive to account for relevant value factors — especially patient diversity — that go beyond population averages. Such innovations are needed to enhance decision makers’ abilities to deliver optimized treatments most likely to benefit patients.

Developing methods and building platforms that provide deeper insights into value is no simple matter, but that can’t be an excuse to throw up our hands and embrace the status quo as “good enough.”

We challenge all stakeholders to commit to bringing forward new concepts and methods for measuring the value of health care. As former Congresswoman Shirley Chisholm often said: “You don’t make progress by standing on the sidelines, whimpering and complaining. You make progress by implementing ideas.”

Jennifer Bright is the executive director of the nonprofit Innovation and Value Initiative. Mark Linthicum is its director of scientific communications.

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