Abstract
The concept of value is receiving greater attention in rehabilitation and the broader health care environment. The overall purpose of this article is to present a framework to help clinicians, researchers, educators, and policy makers better understand the role of health services research in developing and evaluating evidence on value in rehabilitation. Value in health care is a multidimensional concept and may be defined differently by various stakeholders, but assessing value typically involves considering a combination of several health and economic outcomes. However, health care stakeholders often lack sufficient information on these outcomes to make well-informed decisions. Health services approaches such as comparative effectiveness research, patient-centered outcomes research, and health economics assessments are some ways to evaluate value. The evidence generated from such studies directly informs decision making and health policy. Rehabilitation professionals have a great opportunity to increase their engagement in describing, evaluating, delivering, and disseminating high-value care, but there are several barriers they need to consider to be most successful. Embracing health services research best practices is essential for advancing appropriate rehabilitation practice, research, and policy and for addressing challenges to implementing high-value care.
Value-based care is an increasingly important concept in medicine and rehabilitation. The Institute of Medicine has emphasized value as an important part of improving health care systems,1 and the American College of Physicians has launched the High Value Care Initiative.2 Formal value-based initiatives, such as the American College of Physicians' recommendations for diagnostic imaging for low back pain,3 have not yet been implemented in rehabilitation, but the value of care is gaining greater attention in the field.4–6 Focusing on value-based care complements the American Physical Therapy Association's core values of professionalism in physical therapy well.7 Following the principles of professional duty, excellence, and accountability through a socially responsible approach creates a pathway to high-value care.
In a resource-constrained health care system, it is inevitable that the concept of value will become a standard component of rehabilitation care, education, research, and policy initiatives.8 However, health care stakeholders often lack sufficient information regarding comparative outcomes (health and economic) and performance in typical, real-world settings to make well-informed decisions on value. Health services research investigates how social factors, financing, organization, technologies, and behaviors affect health outcomes, quality, access, and costs of health care and health care systems.9 Therefore, health services research frameworks and approaches can inform rehabilitation providers about methods for evaluating value and then how evidence may influence value perceptions of multiple stakeholders.
This article provides a framework to help rehabilitation professionals better understand and assess value in health care (Fig. 1). The 4 objectives of this article are: (1) to provide value-related definitions and examples of outcomes used by various stakeholders for assessing value in health care, (2) to discuss how common types of health services research can generate clinical and economic evidence for assessing value, (3) to outline how health services research can inform the decision making of stakeholders, and (4) to describe opportunities and challenges for rehabilitation professionals in delivering value-based care using health services research.
Conceptual model describing the role of health services research in developing and evaluating value. The conceptual model may not be used or reproduced without written permission from the authors.
Defining Value in Health Care
Value in health care is a multidimensional concept and may be defined differently by various stakeholders, such as patients, caregivers, providers, payers, or society as a whole. Traditionally, economists define value as being directly indicated by price and consumers' willingness and ability to pay for a good or service. In well-functioning markets, prices are able to fluctuate up and down and serve as resource allocation mechanisms in response to “demand and supply” factors. For markets to function well, there should be high levels of transparency and low levels of uncertainty.10 However, health care delivery often lacks both of these attributes along with other features of competitive markets, such as the mismatch between risk bearing and costs.11 Therefore, health care markets often do not function well, leading to inefficiency or distortions in the allocation of resources (or prices). As a result, price (or reimbursed amount) is an unreliable reflection of value, and additional information is needed to help stakeholders make decisions.
In health care, health and economic outcomes are often used to assess the basic components of value. The Institute of Medicine suggested that value in health care is “expressed as the physical health and sense of well-being achieved relative to the cost.”1(p73) High value in health care, therefore, means getting the right care at the right time to the right patient for the right price.”1(p73) Porter proposed a similar but more defined perspective and described value as the “health outcomes achieved per dollar spent.”12(p2477) Intrinsic to both of these definitions is that high-value care results in more efficient health care spending, which is not simply a reduction in costs. These concepts are essentially 2 points of the triple aim developed by the Institute for Healthcare Improvement: improved population health, lower per capita costs, and better patient experiences of care.13
Definitions of value may vary depending on the perspectives of stakeholders.1 In a complex health care system, there are many stakeholders or participants of interest: patients, caregivers, clinicians, hospital or clinic administrators, third-party payers, private organizations or foundations, and governmental agencies. Patient-centered value is an important focus for all stakeholders, but they may have different definitions of what constitutes high-value care and who should pay for specific types of care.
Definitions of value among various stakeholders may depend on how each component of value is measured and the objective of the organization or individual. Better health or well-being can be measured in different ways. Porter12 noted that a single health outcome is not sufficient for assessing value. Health is multidimensional, and appropriate outcomes vary by condition.12 In rehabilitation, the World Health Organization's International Classification of Functioning, Disability and Health framework has been emphasized as a way to more consistently and comprehensively assess multiple domains associated with functioning, health, and disability.14
Examples of Outcomes Used for Measuring Value
Because value and better health outcomes can be defined and measured in different ways, consumers of health services research in rehabilitation need to consider multiple health and economic outcomes when examining how a health service may provide value to stakeholder groups.
Quality of Care
Quality is one of the primary components of high-value health care. Quality of care has several domains, and the Institute of Medicine's 2001 report titled Crossing the Quality Chasm: A New Health System for the 21st Century is an excellent framework for conceptualizing the measurement of quality of care.15 In that report, 6 aims for quality of care were outlined: effectiveness, efficiency, patient centeredness, timeliness, equity, and safety. These components are further described in Table 1, and safety is discussed below.15
Aims for Quality of Care15
Although mentioned as a component of quality of care, safety has been argued to be an independent outcome in the assessment of value.12 Safety is an important outcome in its own right because examining both the benefits and the harms of health services provides a more complete, comprehensive perspective. Improving safety and reducing harms are priorities for many stakeholders in health care.16 Enhancing safety can focus on preventing falls and injuries, reducing hospital-acquired infections and hospital readmissions, and eliminating medical errors.
Clinical Outcomes
In rehabilitation, the clinical effectiveness of interventions is often assessed with condition-specific measures of function, such as the Roland-Morris Disability Questionnaire for low back pain17 or the Functional Independence Measure for neurological disorders,18 and generic health outcome measures, such as the EQ-5D (http://www.euroqol.org/about-eq-5d.html) or the Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire.19 Condition-specific measures allow comparisons of clinical outcomes among patients with common health conditions or involved body regions. Generic health outcome measures allow comparisons of health states among different health conditions or different body regions, but they may be less responsive to change.20
Patient and Caregiver Satisfaction
Satisfaction with care is likely an important component of one point of the triple aim—better patient experiences of care—and it is a common measure of quality of care. However, patient satisfaction is not clearly defined, and it is not necessarily associated with patient outcomes.21 Patient satisfaction is multidimensional and may encompass access to care, provision of health information, patient-staff or patient-provider relationships, shared decision making, the technical provision of care, effectiveness of treatments, and overall satisfaction.22 Additionally, satisfaction may include patients' prior preferences and expectations.23 Not all of these domains are considered outcomes of care. Sitzia and Wood23 and, later, Porter12 argued that some domains of patient satisfaction are not outcomes but rather are processes of care. Porter advocated emphasizing patient satisfaction with outcomes in the measurement of value.12 Even without a single definition of patient satisfaction, several standard measures can be used to assess it.22,24
Costs
Costs are a foundational component of the measurement of value in health care. Costs of a health service or program may be measured as direct or indirect, and costs may be incurred by providers, patients, payers, and society. Direct costs are current and future monetary expenditures occurring from the implementation of an intervention or program. Indirect costs are secondary and may be related to reduced productivity, time lost, or lost work days.25 Because costs are incurred by multiple stakeholders, value assessment can be stakeholder dependent. For example, copayments for physical therapy visits may vary considerably by clinical site, coverage plan, and insurance provider.
Types of Evidence for Assessing Value in Rehabilitation
It is imperative that rehabilitation clinicians, researchers, educators, and policy makers understand how value is being evaluated in the current health care environment so that they can better assess, describe, and produce high-value care. Health services research can help stakeholders and decision makers appraise clinical components of value (health outcomes), economic components of value (value for money), and affordability (budget impact) to aid in health care decision making (Fig. 1). We have chosen to focus on 3 common areas of health services research because they are frequently encountered, they are receiving greater emphasis in terms of funding support and research prioritization, and their details may still be unclear to many rehabilitation professionals. We recognize, however, that many other types of health services research (eg, evidence reviews, implementation science) may be useful for informing decision making as well.
Comparative Effectiveness Research
The term comparative effectiveness research (CER) has captured the attention of the biomedical community, including clinicians, the public, patients, and advocates.26 There are many similar definitions for CER. The Institute of Medicine defines CER as “the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care.”27(p29) Many have stated that the methodology of CER is not new; however, the funding emphasis has certainly increased since the American Recovery and Reinvestment Act of 2009, with $1.1 billion in appropriations for future studies.26,28 After this investment in CER, the Institute of Medicine convened a panel in 2009 to make recommendations for CER priorities, many of which directly involve rehabilitation care.29
Effectiveness research differs from efficacy research in study design, generalizability, and interpretation. Efficacy studies are randomized controlled trials comparing an intervention with a control, which may consist of a placebo or sham treatment, in a carefully selected group of participants under well-controlled conditions. However, such controlled situations may not be generalizable to typical clinical situations or patients. Therefore, efficacy studies may be limited in improving clinical decision making for clinicians and patients.
Effectiveness research involves the direct comparison of the outcomes of 2 or more interventions in “real-world settings.” The Department of Health and Human Services explicitly placed the terms effectiveness and real-world at the leading edge of the definition of CER to distinguish it from efficacy research.30 In comparative effectiveness research, various evidence sources are used: systematic/evidence reviews; secondary, observational data; and randomized controlled trials. Therefore, CER seeks to improve value by providing patients, health care providers, and other key stakeholders with better information about the risks and benefits of different treatment options. Comparative effectiveness research takes a more realistic, pragmatic, and generalizable approach than many clinical studies in the mission to identify what actually works for patients.30
The number of CER studies in rehabilitation is increasing. Two examples in which methods of delivering physical therapy care were directly compared are provided here. Allen et al31 set out to determine whether a 12-week group-based physical therapy program would result in significantly greater self-reported improvements in pain, stiffness, and function than usual-care physical therapy in veterans with knee osteoarthritis (OA). In that study, examining the effectiveness of a common intervention (physical therapy) delivered via an alternative model that is typically used in the Veterans Affairs health care system might provide patients with information on value.31
In another example, Fitzgerald32 set out to determine whether “booster sessions” (periodic face-to-face follow-up appointments after discharge) combined with manual therapy and exercise therapy would improve the effectiveness of rehabilitation over the current state of practice in patients with knee OA. In that study, 2 physical therapy interventions commonly used for knee OA in clinical practice were compared. A better understanding of the effectiveness of these interventions along with added booster sessions can add value for patients, providers, and key stakeholders.32
Patient-Centered Outcomes Research
Patient-centered outcomes research (PCOR) has a methodological focus similar to that of CER, but with the additional component of strong patient and stakeholder engagement. With PCOR, the patient is at the center of an investigation encompassing the evaluation of questions and outcomes meaningful and important to patients and caregivers.33 The goal is to help “people and their caregivers communicate and make informed health care decisions, allowing their voices to be heard in assessing the value of health care options.”34 Therefore, patients and stakeholders are intimately involved in all stages of research: grant development, grant review study sections, study implementation, and dissemination of study results. To foster the development of PCOR, in 2010 the Patient Protection and Affordable Care Act created a new public-private entity, the Patient-Centered Outcomes Research Institute, committed specifically to the development and funding of PCOR.35 Therefore, the mission of the Patient-Centered Outcomes Research Institute is to be a home for public-private investments and research on PCOR.36
A physical therapy–specific example of PCOR was an evaluation of physical therapy versus Internet-based exercise training for patients with knee OA by Allen.37 In that study, stakeholder engagement was used throughout the research process to compare the effectiveness of usual-care physical therapy with that of an Internet-based exercise program, and both programs were compared with a “wait-list control.” Key stakeholders were involved in protocol development, grant submission processes, drafting of articles, and monthly study team phone conferences. Key stakeholders included patients with knee OA, primary care and specialty physicians who treated patients with knee OA, and local and national leaders in OA research and policy development. The purpose of this involvement was to ensure that key stakeholders had the opportunity to provide input during each step of the study process so that the results would be meaningful for decision making related to the management of knee OA.37
Health Care Costs in CER and PCOR
The role of cost-effectiveness analysis in CER and PCOR has been subject to substantial news and debate. Despite the fact that federal support for CER has been perceived as a mechanism for regulating health care costs, costs are not mentioned explicitly in CER legislation.38 Furthermore, a component missing from the many definitions of CER and PCOR is their relationship with cost-effectiveness analysis. Some authors view cost-effectiveness analysis in CER as eventually leading to health care rationing by the government,38 whereas other authors have argued that costs are an integral part of health care decision making and that excluding costs in research does not adequately address the problem of rising US health care costs.28
Health Economics Analysis
Although analysis of costs is explicitly omitted from many CER and PCOR definitions and agendas in the United States, health economics analysis is used by health services researchers as a way to evaluate value. Society and its public and private stakeholders have limited resources. Consequently, stakeholders must make choices regarding their willingness and ability to pay for different types and amounts of health care. To assist in decision making, health economics assessments provide stakeholders with comparative information on incremental differences in costs, risks, and benefits, along with the intensity of health services used. Public and private payers can then conduct budget impact analyses with clinical data, volume of use, and costs to estimate the financial impact of a health service or procedure.
There are several types of health economics assessments, and they vary on the basis of the outcomes used and how the results are presented. Of these methods, cost-effectiveness analysis is the most common (Tab. 2).39 In cost-utility analysis (a specific type of cost-effectiveness approach), effects are measured in quality-adjusted life years (QALYs), a metric including survival time and quality of life.40 Preference-weighted health-related quality-of-life measures, called “utility values,” are used to determine QALYs. They are weighted from 1 (perfect health) to 0 (worst health/death). Multiplying this weight by the life years of an individual provides the QALY estimate.
Types of Health Economics Analyses
Cost-effectiveness and cost-utility analyses conventionally present comparisons as incremental cost-effectiveness ratios (eg, cost per improvement in an outcome) or incremental cost-utility ratios (cost per QALY gained). An incremental cost-effectiveness ratio is the ratio of the difference in cost (direct or indirect) to the difference in effectiveness for 2 treatments being compared. Incremental cost-effectiveness ratios can be viewed and interpreted graphically by use of the cost-effectiveness plane (Fig. 2). Inherent in this schematic are the concept of trade-offs and an understanding that “cheaper” treatments are not always cost-effective; “more expensive” treatments may be cost-effective, depending on an individual's willingness to pay for the benefit; and cost cutting does not always result in high-value care. Stakeholders can use this type of information to assess outcomes of interest to decide whether they are willing to pay for the added benefit of a more expensive product or service.25
Cost-effectiveness plane for evaluating value for money.
A health economics assessment requires a specified stakeholder perspective and a time horizon for the analysis. The perspective of the analysis describes whose costs and outcomes are being measured. The societal perspective is the broadest, most comprehensive viewpoint. This perspective attempts to consider all costs, including indirect costs, and outcomes for everyone affected by a treatment or service. In practice, accurately measuring all costs and outcomes can be challenging, and some authors have suggested that a “limited societal perspective” better describes the approach typically taken.41 A payer perspective is also commonly taken because payers frequently purchase most medical goods and services. The payer perspective focuses more on direct costs of health services and often does not consider indirect costs, quality of life, or nonmedical costs.
The time horizon is the length of time over which costs, risks, and benefits are evaluated. Ideally, the time horizon corresponds to the typical time course of a health condition (ie, an acute condition versus a chronic condition). This approach allows both up-front costs and appropriate downstream costs and outcomes to be taken into account. Including downstream costs is important because they are consequences of using an intervention or service.
Cost-effectiveness estimates can vary depending on the test, intervention, or program used as a comparison; the setting; or how the test, intervention, or program was delivered. Several additional concepts are important for interpreting health economics analysis, and further details on reporting health economics analysis are provided by the CHEERS Good Reporting Practices Task Force.42
A study of stratified care with the STarT Back tool is an example of a cost-effectiveness study alongside a clinical trial. In that trial, Hill et al43 used a “limited societal perspective” by including payer costs based on utilization, patient costs based on out-of-pocket expenses, and indirect costs based on amount of work time missed. They estimated QALYs over a 12-month time horizon using the EQ-5D, a preference-weighted utility measure. The differences in costs and effectiveness (QALYs) between the stratified-care group and the usual-care group were presented as typical incremental cost-effectiveness ratios. They found that the stratified-care approach was superior to the usual-care approach; it resulted in greater QALYs at lower costs. An additional sensitivity analysis showed that the stratified-care approach was dominant in 92% of replications, suggesting that this intervention was highly cost-effective.43
Decision Making Based on Evidence of Value
Evidence generated from CER, PCOR, and health economics analysis directly informs stakeholders' decision making, including decisions about policy (Fig. 1). The World Health Organization defines health policy as “decisions, plans, and actions that are undertaken to achieve specific health care goals within a society.”44 Health policy based on evidence of value is a pathway for implementing high-value care, and public health guidance from the National Institute for Health and Clinical Excellence in the United Kingdom is an example of how research can be used to inform policy.45 To produce evidence sufficient to inform policy changes, rehabilitation professions must enhance their capacity to perform health services research in multiple priority areas. Doing so involves both the cultivation of more rehabilitation health services researchers and the creation of incentives to conduct such research. The recent creation of a Center of Excellence in Physical Therapy Health Services and Health Policy Research and Training from the Foundation for Physical Therapy46 is a great first step, and additional incentives to sustain such research efforts are important for long-term success.
Many policy decisions involve reimbursement of and incentives for health services. Payments are shifting from procedure-based payments to bundled payments linked to outcomes (“pay for performance”). How to implement these changes is under debate,47 but most of the changes are aimed at incentivizing high-value care and improving efficiency. Policy makers use CER, PCOR, and economic analyses to inform these decisions. If rehabilitation researchers do not produce sufficient quality and quantity of evidence, then policy decisions affecting rehabilitation professionals, patients, and caregivers will be based on partial evidence and may be biased toward controlling costs rather than producing value.
Using Health Services Research to Better Deliver Value-Based Care
Improving the delivery of high-value care involves implementing strategies that incorporate multidisciplinary health services research approaches. Stakeholders, such as clinicians, patients, administrators, payers, policy makers, and researchers, can make important contributions to this process and should work collaboratively. We recommend several steps that stakeholders can follow to establish priorities and strategies to generate better evidence through the implementation of health services research, with the goal of providing sustainable value-based care. This process involves the following sequence:
Identify important evidence gaps and target health conditions
Prioritize evidence gaps and target health conditions
Develop a comprehensive strategy to address the top priorities
Invest in the research and researchers to produce the required evidence
Evaluate and disseminate the findings to all relevant stakeholders
Work with stakeholders to develop health policies and decision-making processes, including the monitoring of outcomes and impacts on budgets
Health services research approaches are central to this ongoing process (Fig. 1). Throughout the process of prioritization, evidence generation, and subsequent decision making, it is important for rehabilitation professionals to be involved in describing, defining, and measuring high-value care in rehabilitation rather than defaulting to the choices of others. Jewell et al proposed a “value proposition” for physical therapy: “reduction of disability and improvement in health status of individuals and populations through more cost-effective physical therapist service delivery.”6(p109) They also suggested how the physical therapy profession can implement this vision. We wholly support this appeal and believe that health services researchers should keep this or similar value propositions in mind to underpin the process of delivering value-based care.
Delivering value-based care with this recommended process requires innovative changes to practice to create better opportunities for rehabilitation professionals. Proposals for restructuring primary care around patient-centered value have been made,48 and innovative restructuring of rehabilitation care also is needed to deliver high-value care. Jette was among those leading the call for such changes by prompting physical therapists to develop “systems skills” and innovative practices to meet the challenges that lie ahead in a changing health care system.49
Further innovation is needed to more quickly and broadly translate known high-value care into rehabilitation practice and policies. To provide high-quality care sooner to more patients, rehabilitation professions and organizations need to develop processes for the rapid dissemination and implementation of best practices. Evidence reviews and guidelines are important mechanisms for disseminating evidence on high-value care; however, large, systematic policy changes and realignment of incentives to promote the adoption of high-value care are needed to consistently implement best practice at scale. Another important role of health services research is to investigate evidence uptake and the real-world outcomes of implementing any health care system changes (Fig. 1).
There is a growing emphasis on better integrating research and clinical practice,50,51 and we recommend that rehabilitation professionals embrace this transformation to produce the required evidence, perform quality assurance activities, and drive the innovation needed in the health care system. The Institute of Medicine refers to this construct as a learning health care system, “…where science, informatics, incentives, and culture are aligned for continuous improvement and innovation.”50(p8) Delivering value to all involved stakeholders is central to the success of learning health care systems,50 and considerable effort is being directed toward creating infrastructure to make such systems possible.52 Involvement in a learning health care system represents an opportunity for rehabilitation professionals to better use information generated from practice to create high-value care. To take advantage of this opportunity, rehabilitation professionals must be ready to apply new knowledge, create innovative systems changes, track the outcomes of these changes, and provide rapid feedback on their experiences with systems of care.
Electronic health records are the foundation of a learning health care system, and they are becoming ubiquitous in practice.53 Electronic health records and administrative data represent a form of “big data” and can be valuable sources of information for health services research evaluating care and the components of value.54 One current limitation of the use of electronic health records for research is the lack of usable clinical measures and patient-reported outcomes. Rehabilitation professionals can overcome this challenge by creating and contributing to clinical registries of patients in common clinical settings or with common health conditions. Registries are useful because they can provide important clinical data on a large number of patients so that patient outcomes achieved in real-world practice can be more efficiently evaluated. The American Physical Therapy Association is investing in a physical therapy outcomes registry, and clinicians, administrators, and researchers should embrace and advance this effort to address top priorities.55 The Agency for Healthcare Research and Quality has provided additional guidance on the use of registries for conducting observational CER.56
One of the primary barriers to creating high-value care is misaligned incentives among stakeholders (eg, industry and payers). Currently, most providers are not reimbursed on the basis of the outcomes, quality, or value they provide. Rather, most reimbursement in the United States is procedure driven and is a function of time spent on patient care. This approach incentivizes more care and procedures and may or may not improve patient outcomes. However, reimbursement is changing, and outcomes data are expected to inform reimbursement decisions. To overcome this barrier, rehabilitation professionals need to consistently measure their outcomes and compare them with benchmarks. They also need to generate evidence and describe what high-value care comprises to better target incentives toward high-value practices.
System fragmentation is another major barrier to implementing high-value care. Currently, health care delivery, data collection, and costs and payments often occur in silos, with a lack of coordination and follow-up among providers for a single patient or group of patients. Delivery of care is not consistent among providers, and there is considerable geographic variability.57 Individual providers can work to improve the quality and value of the care that they provide, but large, systematic policy changes and realignment of incentives are needed to effect consistent measurement and delivery of high-value care across the population. Accountable care organizations are a new format through which health care systems and providers can reduce fragmentation in the delivery and reimbursement of care. Health services research will be important in informing strategies through which rehabilitation professionals can contribute to these organizations and other innovative restructuring efforts to minimize system fragmentation.
Conclusion
Assessing value in rehabilitation is an evolving concept. Rehabilitation professionals have a great opportunity to increase their engagement in describing, evaluating, delivering, and disseminating high-value care. The health services research frameworks presented here support the efforts of rehabilitation professionals to better understand and appraise value in health care. This knowledge is essential for advancing rehabilitation practice, research, and policy and for overcoming barriers to implementing high-value care.
Footnotes
Dr Rundell, Dr Goode, and Dr Bresnahan provided concept/idea/project design. Dr Rundell, Dr Goode, Dr Friedly, Dr Sullivan, and Dr Bresnahan provided writing. Dr Rundell provided project management. Dr Jarvik provided fund procurement and facilities/equipment. Dr Goode, Dr Friedly, Dr Jarvik, Dr Sullivan, and Dr Bresnahan provided consultation (including review of manuscript before submission).
This project was supported by grant K12HS022982 from the Agency for Healthcare Research and Quality (to Dr Rundell). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
- Received January 22, 2015.
- Accepted August 18, 2015.
- © 2015 American Physical Therapy Association
References
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