INTRODUCTION

National efforts to improve the value of health care must include graduate medical education (GME) if they are to succeed.1 Accordingly, in 2010 the Medicare Payment Advisory Commission (MedPAC) proposed to reallocate over one-third of the current $9.5 billion of Medicare funding towards GME as performance-based payments, rewarding residency programs that educate physicians on the basis of the following: integration of community-based care with inpatient care, practice-based learning and improvement, and systems-based practice.1,2 In addition, it has recently been proposed that providing high-value, cost-conscious care become a new core competency for training physicians.3 Such proposals skip a key step: residency programs currently lack a clear strategy to prepare residents to assess and deliver value-based care.

The task of training physicians about value is akin to learning an entirely new language for teachers and learners alike. In a national survey, less than half of graduating U.S. medical students felt appropriately trained in topics such as health care systems and medical economics.4 In our prior work, we have described the complex historical and cultural reasons why these gaps in medical education exist.5 Thus far the conventional wisdom has been that time spent teaching these concepts would detract from other curricular clinical components; evidence now suggests otherwise.4 Teaching these concepts requires a multi-disciplinary faculty not abundantly available at many institutions, and there is a general lack of research on best methods for curricular development in this area.5 Under these circumstances, it will be challenging to train residents to implement new approaches to value-based care building on concepts such as comparative-effectiveness research.6 Ideally, prior studies of content development and assessment methodology would be reviewed to establish a core curriculum. Unfortunately, there is a paucity of research on evaluating methods to teach these concepts.5 Therefore, medical educators have no guidance on how to redesign residency curriculums.

Recently, we proposed standards for a national curriculum in health policy for medical schools to begin training future physicians in the foundations of these topics.5 The curriculum focuses on four domains: systems and principles, quality and safety, value and equity, politics and law. As medical schools look for opportunities to adapt their health systems and policy curricula, teaching hospitals similarly need a strategy to improve GME in this realm.

In this article, we present the VALUE Framework for programs to utilize to teach residents to assess and deliver value-based care for their patients. We then present more than twenty opportunities for residency programs to incorporate training in value-based care. The VALUE Framework is aligned with all six general competencies set forth by the Accreditation Council for Graduate Medical Education7 and with the proposed 7th competency of providing high-value, cost-conscious care.3

What is Health Care Value?

Health care value, defined as the health outcomes achieved per dollars spent, has become a cornerstone of the strategy to restructure the U.S. health care system.8–11 An essential component of the value definition is that, while it incorporates cost, it is not only about cost. Comparative-effectiveness research has arisen as a tool for helping clinicians to assess the value of medical interventions.6,9 However, physicians and trainees alike have long struggled with applying policies developed for populations to their assessment and care of individual patients.12

The VALUE Framework

In Table 1, we present a framework for a resident to assess whether a medical intervention will provide value for his or her patient. Case examples demonstrate opportunities for residents to practice and learn these principles. Residency programs can utilize this framework to implement initiatives to incorporate concepts of value-based care. In the following sections, we expand upon the components of this proposed framework, which forms the mnemonic VALUE.

Table 1 A Framework for Residents to Assess Value from a Medical Intervention for their Patients
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Validation and Variability

The initial step for a resident to evaluate whether a medical intervention will provide value for a patient is to determine if it has been validated through evidence-based medicine from rigorous research trials or if it has been used despite weaker evidence. This requires discussion of various research methodologies and their levels of rigor, along with translation of statistical significance to clinical significance. This could be taught during journal club or teaching rounds, within the context of clinical questions. Residents must understand the terminology and validity of not only randomized control trials but also of other reported results, such as associations found among cohort studies or odds ratios from case–control studies.

Understanding variability is of utmost importance when attempting to apply the outcomes of population-based research to individual patients. Certain medications may be very effective in a specific cohort, but individual differences in age, ethnicity, comorbidities or behavior can greatly affect the benefits of an intervention. It is also important to recognize the variability of diagnostic tests, interventions and outcome measures. For example, lab variation in reporting of the hemoglobin A1c delayed its adoption as appropriate screening for diabetes by several years.13 Considering subtle, yet identifiable variability between individuals or outcomes in tests and diagnostics can lead to dramatic differences in achievable value from a medical intervention.

Affordability and Access

Health care varies tremendously in terms of the cost per intervention, and patients vary in their ability to afford health care. Health insurance coverage plays a pivotal role in determining affordability, but at times interventions are not covered by payers or require special authorization. Moreover, a significant proportion of the U.S. population lacks health insurance. Evaluating whether a medical intervention is affordable for a patient is important for two reasons. First, patients are more likely to adhere to interventions that are less expensive, such as when generic medications are compared to brand names.14 Second, no care translates into no value for the patient. Teaching residents how to best identify resources or alternative treatments can lead to improved value for patients—including in situations when not intervening may provide the most value of all. An example of reducing medication cost beyond using generics is the use of pill-splitting, which has been shown to potentially save patients thousands of dollars per year.15

Limited access to medical care can create barriers to maximizing value from a medical intervention.16 Residents who can better identify practice settings or patient populations at risk for limited access to care have been found to be better prepared to provide appropriate counseling to patients.17 Providing equitable care to all patients has been a primary goal of health care systems in the U.S. Yet, health disparities still exist and are an important consideration when evaluating a patient. By identifying patients with limited access to care, proper resources can be utilized to address barriers that may limit value-based care.16

Long-Term and Less Side Effects

When evaluating a patient, residents should remember to consider the long-term horizon to recognize medical interventions that might lead to lasting benefits. For example, when evaluating a patient with multiple medical problems in the outpatient setting, identifying opportunities for prevention such as age-appropriate cancer screening can produce meaningful value to patients over time. Despite national guidelines for preventive care and screening, the U.S population has yet to fully utilize their potential long lasting benefits.18

Side effects from interventions such as medications can impact adherence and sometimes worsen a patient’s quality of life. Side effects differ from adverse events in that they are known and predicted consequences of medication or intervention. Adverse events, in contrast, are rare and often unforeseen. Both side effects and adverse events can be either minor or more serious. However, side effects are often known at time of medical decision making and should play a role in determining which intervention has a lower likelihood of side effects and might provide more value.

Utility and Usability

The balance between utility and usability is important when considering whether an intervention will provide value. Medical utility refers to the desirability of a health outcome.12 It can reflect the patient’s preferences before and after an intervention. The amount of utility obtained from conducting an intervention should be considered for each individual patient. A test that might offer more information but ultimately does not improve the quality of life of a patient should be reconsidered.

Usability refers to the patient’s willingness and ability to adhere to the intervention. For example, reviews of various drug dosing regimens and associated adherence finds that less frequent dosing (e.g. daily rather than three times a day) is associated with improved adherence across multiple therapeutic classes.19 Indeed, these effects translate into improved clinical outcomes and value for patients. A study among HIV patients found that improved medication adherence was strongly predictive of undetectable viral load within six months of initiating therapy.20

Effectiveness and Errors

Interventions that work within controlled settings are defined as efficacious. However, efficacy does not always translate into similar effective outcomes in real-world settings. When reviewing published studies on medical interventions, one must carefully evaluate whether the outcomes were shown to be effective and apply to the patient since many differences between efficacy and effectiveness are due to variations in patient populations or differences in settings.

Medical errors and adverse events are a risk with all interventions. However, the likelihood of errors or adverse events as well as their associated consequences can vary tremendously. An invasive procedure such as central line placement could lead to a pneumothorax. However, if the patient is decompensating from septic shock, then the benefits from establishing central venous access may outweigh the risks. Certain identifiable patient-specific circumstances such as anticoagulation (e.g. fall risk, alcohol intake, age, etc.) should be evaluated as well. Ultimately all interventions carry some risk of error; however, their likelihood and consequences must be weighed against the potential effectiveness of the intervention to determine whether it might create value for the patient.

Incorporating Value-Based Care into Residency Training

Resident training is much akin to an apprenticeship where learning occurs concurrently with providing care for patients. Our own experiences with teaching concepts of value-based care have been well received in the context of patient-based discussions. However, to achieve a more meaningful impact, a systematic approach must be taken to match fundamental training in value-based care to the teaching dynamics within residency programs. The process of teaching residents involves several stages in various clinical and non-clinical settings.21 Structured teaching is conducted through conferences, simulations, and journal clubs while clinical teaching occurs during rounds and at the patient’s bedside. Measurement and evaluation of resident performance is primarily based on attending and peer evaluations that are supplemented with scores from in-training exams and online modules.22 The learning process becomes iterative through feedback from program directors, attendings, and peers.

In Table 2, we provide specific recommendations for residency programs to incorporate concepts of value-based care into structured teaching, clinical teaching, measurement and evaluation, and feedback. Over time, concepts of value-based care must be integrated into all facets of graduate medical education to have a meaningful impact on patient care. As measurement and evaluation of resident performance in this area will be vital for determining whether program initiatives have been successful, further research is necessary to better understand the proper methods for these stages of teaching.

Table 2 Opportunities for Residency Programs to Incorporate Training in Value-Based Care
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CONCLUSIONS

National efforts to improve value-based care must include graduate medical education if they are to succeed. Residency programs currently lack a clear strategy to prepare young physicians for this important task. The VALUE Framework provides a simple and concise method for residents to assess whether an intervention might create value for their patients. Opportunities for residency programs to utilize and test this framework within structured and clinical teaching, measurement, evaluation, and feedback might lead to further improvements in training residents to provide value‐based care.