Last week, millions of people rushed to stores on “Black Friday,” in search of “value.” In that context, value simply means how much do I get, for how much money? Sometimes the calculation is straightforward: a video game for $75 is a better value than the exact same game for $100. Then there might be a simple trade-off. A mixer with 10 attachments for $200 vs. one with 7 attachments for $180. Hmm, the per-attachment cost is certainly lower with the 10 attachments, so the extra $20 is probably worth it. Unless I’m never going to use the additional 3. So it’s a better value for some people, but not others. Going one level deeper in complexity: I know I want the 10 attachment version, and I can get it for $180 if I go to the store at their “early bird” opening at 6 am. Is it worth it for me to get up early to save the $20. Not if I’ve been working 12 hour shifts all week and this is my one day to sleep in, but it might be if I have to be up anyway. And so on.
The point of all of this is that value can be a deceptively simple concept. We’ve all started talking about it, and many people can blithely define it as quality÷cost, as we see on some of the ID lanyards on campus. But when we start to dig it becomes more complex. We’ll explore this all in future posts.
But for now, I want to ask – did my discussion of buying video games and blenders cause an instinctive “what can this possibly have to do with health care response”? Be honest – I’m sure it did for many. Yes, we’ve started to talk about value in health care, but it’s been a rather hollow, rote discussion, almost as if we hope that by saying the words we won’t have to embrace the concept, much less deliver on it. We’ve been mostly talk, little action.
We physicians and other providers take care of patients, with all of the professional obligations that entails under the Hippocratic Oath and various laws and customs. But we also deliver a service, health care, to customers. There, I said it. Many of us have an almost visceral reaction to that word, or the equally obnoxious “client.” Now, I want to be clear – I do not mean to suggest that there is nothing different between being a consumer of health care and any other product or service. There are absolutely many unique things about being a patient (and for that matter, between being a health care provider and being a chef or a financial planner or any other kind of service provider). I do suggest that there are also commonalities, and if we do not start to acknowledge those commonalities – the fact that we serve both patients and customers – our ability to serve our patients will be significantly diminished, because we will lose them.
Here are a few brief illustrations. Until a few years ago, a not uncommon cause of complaints in the ER was from parents saying we did not perform a test or provide a treatment they thought was necessary – why didn’t they do a CT on my child with abdominal pain, for example. I NEVER saw one complaint that we had done too much. Yet in the past few years, those complaints have become common – if a CT is done to rule out appendicitis and it turns out to be negative, the parent complains that it was “unnecessary.” What has changed? Mainly co-pays. Families are now beginning to ask if what they are paying is worth it: what is the value? We also hear from primary care providers within our own system that families ask to be referred to outside providers, because they receive much higher cost sharing from our hospital-based clinic structure. It’s not that they don’t think many of our specialists are outstanding, they just aren’t sure they are getting anything more, or enough more to be worth the extra cost. Similarly, the family of the child getting the CT is undoubtedly thrilled that their son or daughter does not have appendicitis, and they may be very grateful for the care received, but wonder if it could have been done some other way at lower cost.
We also need to keep in mind that our customers may not be our patients. Increasingly, choices to families are being limited by narrow network plans and other types of arrangements. It’s the one buying the service who is the customer. Having great quality doesn’t help anyone if they can’t access it because an employer decides our services do not provide enough value, and they steer their employees to other systems.
(Perhaps we just need to get over our linguistic sensitivities. Patient comes from the Latin patientem, “one who suffers.” That describes some of the people we care for, but not necessarily all of them. Children seeking well or preventive care are probably not suffering. Moreover, if a child comes in with a condition and we treat it, I hope they’ve stopped suffering even if they remain our patient. Customer has an interesting etymology, from the Latin consuetudinem, meaning “usual, or ordinary.” In English, the word customer was first used to describe someone who collected “customs”, which referred to a usual, or routine, fee on goods. It later came to be broadened to mean anyone with whom one had dealings. But the Latin root itself is derived from com- (“with”) and sui, meaning “self”. That doesn’t seem too threatening to the special relationship between health care providers and those they care for. And client comes from the Latin clinare, “to incline or bend” – one who leans on another for protection. In the Latin it referred to someone under the protection of another. That seems suitable, too.
Enough digression. My point is this: we take care of patients and serve clients or customers at the same time. In the actual provision of care, I will always be thinking about the patient in front of me and his or her medical needs. But I also recognize that they are not just looking for quality care, they are looking for value. If our care is going to cost more, the difference in quality has to be worth it to them, or those people will go somewhere else. We will have lost both a customer and a patient. And I think in that case, both they and we will suffer.