新作坊

High-Value, Cost-Conscious Health Care: Concepts for Clinicians to Evaluate the Benefits, Harms, and Costs of Medical Interventions

摘要：

Health care costs in the United States are increasing unsustainably, and further efforts to control costs are inevitable and essential. Efforts to control expenditures should focus on the value, in addition to the costs, of health care interventions. Whether an intervention provides high value depends on assessing whether its health benefits justify its costs. High-cost interventions may provide good value because they are highly beneficial; conversely, low-cost interventions may have little or no value if they provide little benefit. Thus, the challenge becomes determining how to slow the rate of increase in costs while preserving high-value, high-quality care. A first step is to decrease or eliminate care that provides no benefit and may even be harmful. A second step is to provide medical interventions that provide good value: medical benefits that are commensurate with their costs. This article discusses 3 key concepts for understanding how to assess the value of health care interventions. First, assessing the benefits, harms, and costs of an intervention is essential to understand whether it provides good value. Second, assessing the cost of an intervention should include not only the cost of the intervention itself but also any downstream costs that occur because the intervention was performed. Third, the incremental cost-effectiveness ratio estimates the additional cost required to obtain additional health benefits and provides a key measure of the value of a health care intervention. Because health care costs are increasing unsustainably, further efforts to control costs are inevitable and essential. A crucial concern for patients, clinicians, and policymakers is whether it is possible to control costs while maintaining or improving the quality of care; that is, how should we undertake cost control? As part of our activities to develop clinical practice guidelines for the American College of Physicians (ACP), the Clinical Guidelines Committee plans to address these questions more directly with articles that highlight how clinicians can contribute to the delivery of high-value health care. We believe that efforts to control expenditures should focus not on the costs or benefits alone but rather on the value of health care interventions The term value has other meanings (Appendix), but we use it as it is commonly understood,as an assessment of the benefit of an intervention relative to expenditures. Judgments about value are fundamental to decision making in most arenas but often have been missing in health care settings. The distinction between cost and value is critical: High-cost interventions may provide good value because they are highly beneficial; conversely, low-cost interventions may have little or no value if they provide little benefit. We can group interventions broadly into 2 categories. The first category comprises interventions that provide minimal or no health benefit. These interventions typically have low value, regardless of their cost. For example, routine (as opposed to selective) imaging studies for low back pain meet these criteria (1–2) because such studies do not improve outcomes and may cause harm. Thus, this practice is wasteful and can be decreased or discontinued without a negative effect (and possibly with a positive effect) on the quality of care. The second category comprises interventions that provide net benefit. Understanding the value of these interventions requires a quantitative assessment of their benefits and costs. Such assessments usually are done as cost-effectiveness analyses, which explicitly delineate the tradeoffs between health benefits and expenditures but do not determine whether an intervention should be offered. Determination of whether to offer an intervention depends on a judgment by the patient or policymaker about how much he or she is willing to pay for health benefits (3). In this article, we briefly review why the delivery of high-value health care is important and then discuss the principles that can help clinicians and policymakers identify and deliver high-value care (4). We emphasize 3 key concepts. First, it is essential to assess the benefits, harms, and costs of an intervention to understand whether it provides good value. Second, an assessment of the cost of an intervention should include not only the cost of the intervention itself but also any downstream costs that occur as a result of the intervention. Finally, the incremental cost-effectiveness ratio, which estimates how much additional cost is required to obtain additional health benefits, provides a key measure of the value of a health care intervention.