Patient perceptions of healthcare value go beyond quality and cost

Like many clinicians and policymakers, cardiovascular disease (CVD) patients define value in health care in terms of the quality and cost of care they receive. But patients also emphasize factors including their communication with, and trust in, the doctors and nurses who provide their care as important measures of value.

These are the findings of a survey of more than 800 CVD patients and caregivers published in the American Heart Association's peer-reviewed journal Circulation: Cardiovascular Quality and Outcomes. Also published is a call to action for adopting a value-based payment model that focuses on long-term disease management and prevention of heart failure, a leading cause of hospitalizations and readmissions nationwide that is projected to cost the health care system $70 billion by 2030.

Both papers are products of the Value in Healthcare Initiative, a collaboration between the American Heart Association, the world's leading voluntary organization focused on heart and brain health, and the Duke-Margolis Center for Health Policy. The initiative was launched in 2018 to convene representatives from across the health care ecosystem to identify and address key opportunities to improve value and transform cardiovascular care.

"Mounting pressures on our health care system leading up to and including the COVID-19 pandemic add urgency to the need to prioritize value and ensure resources best serve the needs of patients and society," said Nancy Brown, CEO of the American Heart Association, and Mark McClellan, MD, Ph.D., director of Duke-Margolis, former Food and Drug Administration commissioner and former Centers for Medicare & Medicaid Services administrator. "Moving from fee-for-service to paying for value in health care—by elevating telehealth and community-based care, making clinical trials more efficient, ensuring health coverage matches care with patient values, focusing on chronic disease prevention, and other efforts—has never been more critical."

Patient Perspectives on Value

One goal of the Value in Healthcare Initiative is to inform the development of patient-centered policies and care delivery programs with an understanding of how CVD patients define value. This paper examines how U.S. patients with CVD define value in health care, how they assess the value of a clinical visit and how satisfied they are with the value of their care.

The survey, believed to be the first to focus on CVD patients and their perspectives on health care value, included patients recruited from the American Heart Association's Support Network online forums and by a private research firm.

More patients surveyed (42 percent) ranked "having knowledgeable and competent practitioners" as the highest measure of value in a health care visit, followed by "financial affordability" (29 percent), "timely access to care" (16 percent) and having "a clear treatment plan" (15 percent).

Findings were similar by gender but differed by age. Older patients were more likely than younger patients to rank having competent practitioners as most valuable to them, but younger respondents were significantly more likely to rank financial affordability as most valuable.

Responses also differed by race and ethnicity. Respondents identifying as African American, Hispanic/Latino or another minority ethnic group were more likely than self-identified whites to rank financial affordability as most important. African Americans, Hispanics/Latinos, and Asians also were more likely than whites to rank treatment based on recommendations from a scientific organization as most valuable.

The two most important items for determining the value of a health care visit were "communications with healthcare providers" and "trust in my healthcare providers." African Americans and Hispanic/Latinos were more likely than whites to rank compassion shown by health care providers as most important.

"When clinicians and policymakers define value, it is often couched in terms of quality or outcomes over price," said Karen Joynt Maddox, MD, MPH, assistant professor of medicine at Washington University School of Medicine in St. Louis and the paper's lead author. "But while patients include quality and costs in their understanding of value, they also emphasize communication and trust. Improving the patient experience has been linked with better clinical outcomes across a broad range of conditions, suggesting that improving trust and communication can lead to tangible changes in health."

Advancing Value-Based Models for Heart Failure

Despite tremendous progress in improving care for heart failure, the quality of heart failure care varies greatly. This paper calls for moving away from the current payment system for heart failure care, which is largely based on fee-for-service reimbursement, leading to fragmented, low-quality care.

The Value in Healthcare Initiative developed a framework for a heart failure model focusing on disease management and prevention that could be compatible with existing payment models. The model's key elements focus on longitudinal care, integrating specialty care into a value-based payment arrangement and promoting team-based care delivery.

"Over the past two decades, spending on cardiovascular care has risen steadily while outcomes for patients have stagnated or worsened," said Dr. Joynt Maddox, the paper's lead author. "These disturbing trends call for a rethinking of our current CVD payment system. This framework is intended to increase value in CVD care by incentivizing risk reduction, improving medication adherence, addressing unmet needs and discouraging inefficiencies in care while improving patient outcomes. Moving from concept to implementation will require collaborative action across the health care ecosystem, involving private and public payers, clinicians and health systems."

Dr. McClellan and Dr. Joynt Maddox also coauthored a perspective on value in health care that describes the Value in Healthcare Initiative's work moving forward to address topics including increasing the efficiency of cardiovascular clinical trials, implementing prevention programs in under-resourced settings and transforming prior authorization as part of a value-based system.