Ethical Debate Surrounds Inclusion of High-Value Care in Medical Curriculum

As the healthcare industry continues its transition toward value-based care, some medical ethicists have raised concerns about how education with an emphasis on value can potentially conflict with patients’ best interests. An opinion letter published in JAMA discusses strategies for addressing these tensions.

The authors wrote that the calculation of value as a ratio of health outcomes to cost presents a number of pathways towards increased value. These methods include achieving better outcomes while marginally raising costs, reaching similar outcomes while reducing unnecessary expenses, or reducing health benefits to minimize spending, which results in a trade-off between quality and cost.

This last scenario is the one that has the potential to create “ethical tension between physicians’ commitment to providing cost-effective care while maintaining the primacy of patient welfare without compromise.” This balance is especially crucial in medical education, when trainees form a professional identity by combining their own personal beliefs with external influences.

High-value care education must instill in trainees a firm commitment to the importance of patient welfare during this formative stage, the authors wrote, instead of opening the door to more debatable cost-quality trade-offs. Teaching “should initially focus on circumstances in which the primacy of patient welfare is clearly fulfilled (ie, not in jeopardy of compromise) rather than circumstances in which there is ongoing controversy” on the definition of value.

Some examples of subjects to approach with caution in value-based care curricula include cost-effectiveness analysis, which has the potential to inadvertently condone withholding beneficial treatments in favor of saving costs. The authors also mention potentially harmful teaching practices like resident competitions to generate the least expensive evaluation, having students allocate budgets across patients, or using tools that track and display patient costs in real time. The emphasis on cost in these activities “could risk causing trainees to lose sight of individual patient welfare.”

Instead, the authors advocate for teaching the benefits of high-value care without compromising patient welfare by educating trainees on how to discuss costs with patients and avoid wasteful services. These approaches, which “tread lightly” in teaching cost-quality trade-offs, are particularly suitable for the earlier stages of medical education.

“Early on, it may be more appropriate to focus on teaching medical students to communicate about costs with patients. Later, more complex concepts of value could be introduced,” lead study author Matthew DeCamp, MD, PhD, said in a press release from Johns Hopkins Medicine. “This is much the same way we teach in other areas of medicine—blood draws first, heart catheterizations later.”