AJMC Editors Weigh in on Value in Healthcare and Use of Preventive Services

Co-Editors-in-Chief of The American Journal of Managed Care, A. Mark Fendrick, MD, and Michael E. Chernew, PhD, and former Editor-in-Chief J. Sanford Schwartz, MD, recently wrote about value in healthcare and the use of preventive services in Health Affairs Blog.

They write that despite the widespread enthusiasm for the increased use of preventive services, there have been some “suboptimal” policy choices that define prevention services as being delivered to individuals who are asymptomatic.

“While we agree that there is value in evidence-based preventive services for asymptomatic people, we feel it is important to recognize that the prevailing focus on primary prevention tilts the system against services often of much greater value: those that prevent adverse consequences associated with diagnosed disease,” Drs Chernew, Fendrick, and Schwartz wrote.

They gave 2 examples where this policy fails. For one, if a woman seeks a mammogram after finding a lump, she must pay, but without finding a lump, a woman over the age of 40 years can get a screening mammography for free. As another example, colonoscopy is free for individuals with no symptoms, but there is a cost for patients who do have symptoms.

“If we are focused on value, why fully cover services that diagnose conditions that are not yet clinically apparent, while exclude coverage of higher value services that effectively manage them?” they ask. “Plans that offer no-cost depression screenings but charge for high value anti-depressant therapies seem to be inconsistent.”

Part of the problem is that “value” is hard to define. This is something that was discussed at length during one of the roundtable discussions at the National Comprehensive Cancer Network 20th Annual Conference.

During the session, Linda House, RN, BSN, MSM, president of the Cancer Support Community, explained that there is a disconnect between how patients define value and how health economics define it.

“So throw in incentives around that and there is a huge disconnect in what’s happening in that decision-making moment,” she said.

Drs Chernew, Fendrick, and Schwartz wrote efficiently promoting value in regulations can be difficult, but they recommend plan design flexibility so that limits can be created while not distracting from the goal of promoting value.

For example, the flexibility to innovate plan designs will improve access to care for patients with health savings accounts, but attract a new group of enrollees who will gain better access to effective preventive services.

“Given fiscal constraints, policymakers must strive to promote use of high-value care and discourage use of low-value care while continuing to promote innovation,” they wrote, but admit “No approach will be perfect…”