The Value of Considering Cost, and the Cost of Not Considering Value

During my residency, which was, alas, some time ago, an attending physician instructed me to order a large battery of tests.These seemed to me to be highly unlikely to affect patient management.I asked him if this was really the best thing to do, and noted that it didn't seem cost effective.He replied to me, with righteous indignation, that it was "…not our job to consider cost" and that "…none of my patients ever paid me to be cost effective."I thought this was wrong then; I know it is wrong now.Whether there was ever justification for our wishful societal delusion that everything we do in health care, and especially cancer care, could and should be above consideration of cost, we are now recognizing, albeit all too slowly, that we can no longer afford this luxurious fantasy.As every drug, device, and intervention we might choose, or not, to use in the care of a patient has a specific and often substantial cost attached to it, we can no longer ignore nor can we blindly accept that cost and feel that it has no place in our medical decision making.To continue to do so would inevitably bankrupt our health care system and prevent us from ever being able to provide necessary quality care for all.In this context, the terms value, value-based care, and highvalue medicine have increasingly entered into our discussions.Often missing, however, in this developing discourse is a clear understanding of what these terms actually mean.Too often an ethereal, vague concept of value is invoked to obscure or avoid a frank consideration of the real, hard cost.A drug regimen that works well is valuable, but if it costs $300,000 per patient per year, as some of our newer regimens do, then I would argue a priori that it costs too much, and a diversion of the discussion away from this hard cost to a vague concept of value can serve as a distraction from confronting this harsh reality.Also lost, or at least underappreciated in these discussions, is that we will accomplish nothing as we confront cost, define value, and embrace high-value care unless we also define and eschew low-value care.This means identifying certain practices that we now perform that we will stop performing, because they offer insufficient value to our patients to justify their continued use.