What Is Value in Health Care?

To the Editor: In his Perspective article, Porter (Dec. 23 issue)1 defines “value” as “outcomes relative to cost.” His views represent a payer-centered perspective rather than a patient-centered one and reduce caring to “services” in a (mythical) health care marketplace. His “value” could reward mediocre outcomes delivered cheaply — a bargain for payers, not patients. Moreover, paying for value on the basis of long-term outcomes in patients with chronic disease will remain an important challenge for the foreseeable future. Value from patients’ perspective — if we were to ask them — should reward high-quality, affordable care, no doubt. But it would also reward practitioners whose care centers around the patient, not solely “value” based on cost, measurable outcomes, and efficiency metrics. Judged by Porter’s metric, “amenities” such as chaplain services, fine art, and an unhurried examination would quickly become extinct.2 More than a decade ago, Cleary et al. identified a patient-centered definition of quality that has gone largely unnoticed in the research and policy communities.3 Unless we start defining value from a patient-centered, not payer-centered, perspective, we will further silence the patient’s voice in U.S. health care.