The Role of Value in the Health Care Economy

The term “value-based care” frequently comes up in discussions of clinical pathways and standards of care. But what does it actually mean? And who gets to define value, and for what patient population? Many parties are involved in conversations surrounding value, encompassing a wide variety of stakeholders that include patients, advocates, providers, administrators, and payers.

In order to better understand the role that value plays in clinical pathways, Journal of Clinical Pathways spoke with Alexander W Bastian, MBA, a member of the journal’s Editorial Advisory Board. Since 2016, Mr Bastian has been head of global value, access, and pricing at Incyte. Prior to joining Incyte, he served as vice president of GFK Bridgehead. Mr Bastian is also an advisor to the American Society of Clinical Oncology (ASCO) Value in Cancer Task Force, through which he has helped to develop metrics for measuring value in the oncology sphere.

What inspired you to work in the Value in Cancer Task Force and what is your role in your position?

The Value in Cancer Task Force set out to to something that had not been done before, at least not in the United States: to define the concept of value and its multiple means of expression in health care. This is something that I have been passionate about, and that reflects the work I do every day. Whenever I have the opportunity to work with people who are proactive and constructive on a topic I am passionate about, it is easy for me to join in on the initiative.

After spending many years living and working in Europe, I became acutely familiar with the differences between European and American decision-making strategies and value assessments. Value assessment in almost every European market has its own unique approaches, and sometimes there are differences of opinions. There are also consequences to these approaches, which can lead to unexpected circumstances that would not be desired by patients, physicians, and manufacturers in America: for example, sometimes patients in Europe do not receive new therapies for several years after they have become standard practice in the United States.

I serve as a strategic advisor to the Task Force. I helped the ASCO leadership committee facilitate some early dialogue and feedback sessions with patient advocates, pharmaceutical leaders, industry groups, and payers. It was important for us to hear directly from groups, and to engage early so that input could be gleaned during the development process. Later on, I helped to test the value framework developed by the Task Force, run case studies, and poke holes in it wherever we could find them. I was supported by a team of intelligent analysts and consults who assisted in this large task.

What do you see as the role of clinical pathways in health care moving forward?

Clinical pathways have been around for a long time. Before they were a concept in their own right, they were common practice in most hospitals and acute care settings. The protocol slowly morphed into the more rigid, multistep pathways that we recognize today. In some ways, the existence of clinical pathways acknowledges two things: that quality of outcomes should be evidence-based, and that variability can lead to worse outcomes and unnecessary costs. However, if there are data gaps—which is often the case in many areas, such as orphan diseases and rare cancers—it is sometimes unclear how we determine the best quality. If there are no comparative trials, how can we determine the best intervention in a given setting?

Clinical pathways are a way for payers to define decision-making to another entity. This may partially be due to impotence in their ability to restrict or block coverage, such as in oncology care. It also acknowledges the importance of shared decision-making and the role of the clinician’s voice in such decisions. Payers are often not concerned with which pathway is used, as long as you are willing to choose one.

Because the American system is a system of disparities, there will be tremendous utility to the implementation of pathways to stamp out poor quality at the bottom end and high costs at the top end. However, there is an art and a human element that must remain in place, and I think there are limits on what clinical pathways can achieve. The question is: what do you do after you have 90% of your patients on pathways, but the costs are still high?

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