#EAPM: Value in modern-day medicine. Who decides?

In health-care systems that are becoming increasing tough to finance, how do we decide what constitutes ‘value’?  Obviously, writes European Alliance for Personalised Medicine (EAPM) Executive Director Denis Horgan, one must understand a product and/or treatment while considering what it can provide, weighed against cost and other considerations, for the benefit of the patient. 

On the latter point, though, how do we assess that benefit?  We can talk about extended lifespans, better quality of life in the run-up to death, treatment that is purely palliative and more. But if the drug, for example, is highly expensive and gives only an extra few weeks of life, or makes the sufferer only marginally more comfortable, is it worth treating the patient at all?

From a humanitarian point of view, many would argue that that answer should be ‘yes’, but that flies in the face of spiralling costs and, sometimes, a lack of proof that a treatment achieves very much.  For certain today, when medical innovations are increasingly prevalent but those under-pressure healthcare budgets are tightening all the time, it is important to find ways to optimise equitable access to healthcare systems and treatments.

HTA bodies are very useful but, in a Europe that sees a lack of equitable access to the best treatments in many of the EU’s member states, a lack of alignment and agreed definitions of value lead to a clear imbalance between richer and poorer countries as well as, often, between different regions within single states.

Interestingly, the US-based Institute of Medicine has identified six value points when it comes to cancer care, and these can equally apply to other diseases. The six points are safety, effectiveness, being patient centred, timely availability, equity and efficiency.

These are all vital to every patient but different health-care systems will evaluate their ‘worth’ differently. The patient, on the other hand, will have his or her own view and, in many cases, we find that quality of life often outweighs length in many patients’ list of priorities.

Society needs to come up with a broad definition of ‘value’ to facilitate universal access to treatments. It becomes clearer with every innovative drug and treatment that new models of value are needed. These should take into account broader societal considerations, and must be transposable and scaleable across chronic conditions.

Due to better knowledge on the part of patients, and the rapid emergence of personalised medicine, those living with chronic diseases are becoming more-and-more expert in the management of their own condition. They are, today, able to identify unmet service needs and point out waste and inefficiencies in the healthcare system. Perhaps health-care systems should start listening a little more…

Research has shown that patient-centred care models are cost-effective and lead to better outcomes and patient satisfaction. Patient empowerment can be a vital element of high-quality, sustainable, equitable and cost-effective health systems.

Patients sharing in decisions about their own health have led us to be able to identify what a sufferer considers to be the best treatment for his or her lifestyle - for example, whether to stop smoking or drinking if it is already too late, whether to seek early breast removal in the face of genetic probabilities or whether to undertake early prostate removal as opposed to waiting.

The Brussels-based EAPM believes that there is a strong argument that the concept of ‘value’ should always be seen from the ‘customer’s’ point of view, in this case, the patient. During the last few years, EAPM has worked with its membership to engage patients, payers, policymakers, academia, and industry to examine various approaches to value assessment - with an emphasis on the world as seen by the patient.

Two recognized experts on value-based health care, Michael Porter and Thomas Lee, have said in the past: “The challenge of becoming a value-based organization should not be underestimated, given the entrenched interests and practices of many decades. The transformation must come from within.” They add: “Only physicians and provider organizations can put in place the set of interdependent steps needed to improve value because ultimately value is determined by how medicine is practiced.”

Porter and Lee also maintain that, in health care, the days of ‘business as usual’ are over. Globally, every healthcare system is struggling with rising costs and uneven quality, despite the hard work of well-intentioned, well-trained clinicians.

They say: “Health-care leaders and policy-makers have tried countless incremental fixes…but none have had much impact. It's time for a fundamentally new strategy.” The pair say society “must move away from a supply-driven health care system organized around what physicians do and toward a patient-centered system organized around what patients need”.

EAPM is a firm believer in this patient-centric approach. The Alliance’s co-chair and cancer specialist Gordon McVie said: “Health care should start with the patient. As should the concept of value. Our viewpoint and strategy is reflected in the landmark Luxembourg Council Conclusions on personalised medicine which state that the EU-28 should take into account, ‘inter alia, added value from the patient’s perspective as well as enhanced cooperation and exchange of best practices’.”

McVie added: “Throughout 2016 EAPM has been following up on the Council Conclusions and will continue to do so into the future. It will also be adding to what the necessary societal great value debate at its fifth annual conference at the end of March next year, as well as at its inaugural Congress in Belfast in November 2017.”

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