Sovaldi® and Curing Hep C – Myths and Other Facts

The introduction of new oral medicines that can cure chronic hepatitis C infections (including Sovaldi®) have led to some intense discussions permeated with misleading information about the pricing of new medicines, how such medicines are “game changers,” and the implications for budget-crunched payers.  Below I summarize some key points about those issues.

1.  Myth #1: How Medicines are Priced

One of the perpetuating myths about biopharmaceuticals is that medicines are priced to recoup research and development costs.1 It’s a myth. As I’ve written about elsewhere prescription medicine prices are set like everything else in a regulated free market: Companies set prices to maximize revenues and profits based upon the market opportunities and the value the new medicine provide compared to the consequences of the disease and other treatment options – including no treatment at all.  (See more about this in #4 below.)

2.  Myth #2: There is A Price

While the price of Sovaldi® has been widely written about in the press, in reality, there is no single price in the U.S. for almost all medicines. Rather, every medicine has a range of prices that include the discounts required by law to Medicaid, VA, DoD and other government programs, and the discounts negotiated by private insurance companies. The widely reported price of Sovaldi®, which is the starting point for those discounted prices, has been widely criticized, but a high-level examination of the situation illuminates a relatively logical picture as discussed below. Furthermore, an understanding of the overall situation with chronic hepatitis C infection and those new medicines leads to a reasonable strategic framework for payers facing significant costs for treating people with chronic hepatitis C infection.

3.  Situation with Chronic Hepatitis C Infection

A.  Most of the roughly 4 million people with chronic hepatitis C in the U.S. were infected before 1992 when a test to screen donated blood started to be used.

B.  Today, the rate of new infections is about 45,000 people per year, and those infections are acquired primarily through intravenous drug use.

C.  The older treatments for chronic hepatitis C infection largely depended on activating the patient’s immune system to clear the virus from the body, which is why the medicines in those treatment regimens, (e.g., interferon) make people feel like they have a bad flu for several/many months.

D.  Assuming patients can tolerate the side-effects and complete their course of therapy, the older treatments for hepatitis C had cure rates2 as low as 20% depending on the strain (genotype) of the virus and certain patient characteristics.

E.  The new medicines for chronic hepatitis C infection are “game changers” since they have reported cure rates of 90-95+%. Ray Chung, MD, a hepatitis C expert, has described these new medicines as a clinical paradigm shift from treating a liver disease to curing hepatitis C infection.

F.  These medicines are also “game changers” because this is the first time biomedical science on earth has developed a cure for a chronic viral infection. (I can’t speak for other planets, galaxies, or other spatial dimensions.)

G.  The low rate of new infections in the U.S. means that if people currently infected with hepatitis C are treated and cured (and the new medicines seem capable of curing people by eliminating the virus from their bodies), then – in theory – hepatitis C infections could be eliminated, or at least driven down to very low numbers.

H.  Physicians (particularly gastroenterologists and hepatologists) were aware that new – and much better – medicines to treat (and hopefully cure) hepatitis C infections were expected to be approved in late 2013/early 2014. Therefore, many patients weren’t started on the older therapeutic regimens that had significant toxicities and low cure rates.

I.  The people who deferred treatment in 2013 were lined up to be treated in early 2014, and this produced a large wave of new patients (and sales) for the new medicines in early 2014.

4.  Rationale for Pricing of Hepatitis C Cures

I stated above that companies price new medicines to maximize revenues and profits.  That’s only sort of true. New medicines are really priced to maximize the value the company will get from selling the medicine over the entire effective life of the product.  Economists refer to this as the “Net Present Value” (or NPV), which takes into account expected revenue in future years, discounted by how much less a dollar in the future will be worth than it is today because of inflation, and other factors such as competition from other treatment options. For Sovaldi® the most significant factors are competition and substitution due to other medicines expected to be approved in 2015 and beyond, AND the limited number of people with chronic hepatitis C infection.

The relatively finite pool of patients means that NPV calculations for Sovaldi® do not look like other medicines to treat chronic diseases or to keep cancers in remission, because those types of medicines have large (and probably growing) patient populations that will be taking those medicines on an ongoing basis. Therefore, the “value” of Sovaldi® in the latter years of its 14-year effective patent life3 will be much, much, much less compared to those other medicines. This front-loaded fiscal/value situation means that setting a ceiling price at the higher-end of the comparable range for treatments for a serious illness that will be taken as a single course for a shrinking population is a logical outcome.

5.  Path Forward for Budget-Crunched Payers

Because Medicaid programs, the VA, and state/local prison systems have significant numbers of people with chronic hepatitis C infection – and they have fixed or semi-fixed budgets – treating everyone infected with hepatitis C all at once would be a significant budget buster. Below I describe a framework for logically approaching this situation.

But first, it is also important to recognize some other factors about chronic hepatitis C infections and Sovaldi® and other medicines that are expected to be approved to treat/cure hepatitis C in the coming months/years:

A.  Of the estimated 4 million people in the U.S. with chronic hepatitis C infection, most do not have significant liver disease characterized by changes in the structure and function of the liver that ranges from various degrees of fibrosis and cirrhosis to full liver failure or liver cancer.

B.  People with more advanced disease are already costing the health system significant amounts and have the most health and quality of life problems.

C.  While the exact percentage of people with chronic hepatitis C who have advanced disease is unknown, a reasonable guess might be about 20-30%.

D.  People who do not have advanced disease will most likely progress to advanced disease, and there are known risk factors that increase the likelihood of more rapid progression.

Given those factors, a reasonable approach for payers with limited resources would be to put those people with advanced disease in the front of the queue for the cure. Other people who should be included in this “first to treat” group would be individuals who have certain criteria that increase their risk for rapid progression of liver problems, or are having health problems from the infection outside the liver (i.e., extra-hepatic manifestations) such as renal, hematologic or rheumatologic problems, or are symptomatic.

Other groups that could be considered for priority treatment could include people in prisons (or being released from prisons) who might be at increased risk of transmitting the virus to others.  (People who are cured of their chronic hepatitis C infection can be reinfected.)

After this first group’s treatment is addressed, the next group of individuals with risk factors for more rapid progression to advanced disease (such as longer time since their estimated date of infection) could be eligible for treatment.

This “triaging” of priorities would spread costs out over a longer period of time in a rational way. In addition, because of real-world barriers to identifying and engaging all potential patients, not all the people in those first to treat categories would get treated in the first few months or year. Therefore, the actual first year costs would be below the results from a simple calculation of the number of people multiplied by the treatment costs per person.

Such triaging would give budget-crunched payers time to plan for future budget years with the realization that the number of people with chronic hepatitis C infection will be decreasing over time.  After a few years of treating people with chronic hepatitis C infection (depending on how the triaging/staging is done, along with the effectiveness of public health outreach and screening) the annual costs for medicines for people with chronic hepatitis C infections should become relatively low even before generic versions of the new medicines are available.

6.  Cures for Chronic Hepatitis C Infection Are Not Game Changer

Some people have angsted about how the new treatments for chronic hepatitis C are harbingers of more expensive, budget-busting medicines. However, looking at the pharmaceutical industry pipeline, there are not medicines in clinical development to cure other chronic viral diseases.  Nor are there medicines to cure other serious chronic diseases.  I certainly wish there was a $100,000 cure for MS, Parkinson’s, Alzheimer’s, ALS, HIV/AIDS, or many other debilitating or degenerative conditions – but there aren’t, and there don’t seem to be any on the near horizon. Thankfully, there are compounds in clinical trials to better treat those conditions by preventing or slowing progression, as has already happened for rheumatoid arthritis and some other autoimmune diseases. Therefore, while the new cures for chronic hepatitis C are game changers for people with that specific condition, unfortunately, cures for other serious chronic illnesses do not appear like they will be available very soon.

7.  Caveats & Other Notes

I apologize for this rather lengthy post – particularly after the long time since my last post.  But there are a few other points to note:

  • These thoughts are my own, nobody has paid me to write this, and only one person reviewed it for gross factual correctness.
  • My projections and estimates of infection and cure rates etc. are derived from conversations with knowledgeable people and reading the literature, but there is clearly a significant level of uncertainty about many of those estimates, including the numbers of people infected and their stages of disease.
  • Even the best projections are off by some significant percentages.
  • The price of other medicines for chronic hepatitis C infection that are expected to be approved in the next 6-36 months are unknown, but the price range for Sovaldi® should set an upper limit based on a course of treatment to achieve a cure. Therefore, for example, if another compound is approved that achieves a similar cure rate with similar side-effects, etc., but only needs to be taken once a week for 8 weeks (i.e. 8 pills), it would likely have a higher per pill price than Sovaldi®, but a lower total cost for a course of treatment.

 Footnotes:

  1. While, the risk of biopharmaceutical R&D is borne by companies, they cannot bake the R&D costs of individual medicines (and dead ends) into the prices of those medicines.  Rather, a company’s profits are the source of funds for future R&D. Specifically, companies makes decisions about how to use their financial resources (primarily derived from profits) for R&D and other activities. R&D opportunities are evaluated based upon the projected market potential combined with the company’s expertise and capabilities that would enable the company to successfully develop a new medicine in a specific disease area of need, i.e., where there is a market opportunity.
  2. Cure is defined as no detectable virus six months after the conclusion of treatment.
  3. http://www.accessdata.fda.gov/scripts/cder/ob/docs/patexclnew.cfm?Appl_No=204671&Product_No=001&table1=OB_Rx

CER, HIT, and Women’s Health Research

Below is a video of my discussion with Phyllis Greenberger, President and CEO of the Society for Women’s Health Research, about the implications of comparative effectiveness research (CER) and information technology for women’s health and quality improvement.

What are your thoughts about CER and HIT?  Will they lead to higher quality, lower cost, or more efficient/better healthcare?  And if so, how soon?


FYI – The SWHR’s July 18-19 meeting mentioned in the video is “What a Difference an X Makes: The State of Women’s Health Research.”

Health Reform and Transformation in San Diego & California

I recently sat down with Kevin Hirsch, MD, President of Scripps Coastal Medical Group* to talk about health reform and transformation in the San Diego region. (See video below.)

Dr. Hirsch’s insights are interesting and timely because California often precedes the rest of the country in adopting new approaches to healthcare delivery and financing problems.  An example of this may be California’s 2006 Hospital Fair Pricing Act, which addressed very high hospital bills for the uninsured. This month’s Health Affairs includes an article that analyzes the impact of this law, and the authors’ findings contrast markedly with Steven Brill’s Time magazine article, “Bitter Pill: Why Medical Bills Are Killing Us.”

The California law is a significant step, and the Health Affairs authors describe it as a “detailed and well-structured approach.” The Act did have  limitations: it only protects uninsured people with incomes under 350% of the FPL, the state has minimal enforcement activities, and it only covers hospital bills and not those from physicians or outside services. (Note: In 2011 the law was expanded to include bills from ED physicians.)

Since the ACA will leave many people without health insurance, the Health Affairs authors conclude, “Policy makers and health planners in other states searching for options to protect the uninsured should be encouraged by our findings and should seek to learn more about California’s approach and determine how they might adapt similar laws to their own state’s health care system.”


(Disclosure: I’ve known Dr. Hirsch for many years – and aside from out obvious East Coast-West Coast attire differences, we continue to share a similar hairstyle and are both working to improve healthcare quality and efficiency.)

 

*Scripps Coastal Medical Group includes more than 140 family medicine, internal medicine, obstetrics and gynecology, pediatrics, physical medicine and rehabilitation, rheumatology and general surgery clinicians practicing throughout San Diego County, and exclusively provides medical services through Scripps Health, a nonprofit integrated health system, under the Scripps Coastal Medical Centers brand.

Health Reform and Low-Income People in Washington DC

I recently sat down with George Jones, Bread for the City’s CEO, to talk about health reform and the challenges low-income people in Washington DC have accessing healthcare. The video of our discussion is below.  A couple of notes: 1. George’s title changed from Executive Director to CEO about a year ago.  I’ve known George for more than 15 years, so my bad when I introduce him as the Executive Director. 2. Please excuse my verbal stumbles and be impressed by George’s answers – we filmed this in one take in his small, hot office at Bread for the City.  I’m confident there will be improvement in future videos – and of course, your feedback is always welcome!

Health Promotion, Prevention, Wellness, and Government Fiscal Policies

I recently had the opportunity to give guest lectures at Georgetown University and the University of Virginia. At Georgetown I focused on employer’s perspectives on health promotion and disease prevention. (Videos of portions of that discussion are below.) At UVA’s Batten School of Public Policy I discussed fiscal issues and policies for government healthcare programs, e.g. Medicare and Medicaid. (A few slides from that discussion are below….. sorry no video.)

The opportunity to talk with our future clinicians, health system administrators, and policy makers was heartening and a bit terrifying. While the students are eager and passionate, I wonder about their historical understanding of our complex healthcare systems and the policies, programs, and initiatives that got us to where we are today. Too often I’ve seen proposals that are trying to resurrect a failed wheel, or undo something that solved a problem so effectively it no longer has a vocal advocacy. As Edmund Burke said, “Those who don’t know history are destined to repeat it.” And the US healthcare system(s) have enough challenges without spending resources on false paths.

Video Segments: Georgetown Univ. Health Promotion & Disease Prevention Guest Lecture

Part 1:

Part 2:

Selected Slides from UVA Batten School of Public Policy Guest Lecture

US Healthcare Spending 1990-2011US Healthcare Spending 2011US Healthcare Funding Sources - 2011US Health Insurance Coverage - 2011

US Healthcare Spending Distribution Across Population

 

Health Propoganda

Zocalo Public Square asked me to write a short answer to the question “What has been your favorite health propaganda campaign in world history–whether for its success or for its other qualities–and why?”

I wrote about the positive contribution of the Robert Wood Johnson Foundation funded Aligning Forces for Quality (AF4Q) initiative, and the negative effects of fake medicines.  You can see my full piece along with the other 6 contributions here: http://www.zocalopublicsquare.org/2013/02/25/this-is-your-brain-on-health-propaganda/ideas/up-for-discussion/

 

Health Spending: For What, To Whom, and Where It Is Heading

The data for 2011 US healthcare spending was reported in the January issue of Health Affairs.  Below are some graphs showing how spending was distributed across the different categories of healthcare services in the years 2000, 2007, and 2011, as well as who paid for the spending.  (My analyses and commentary follow these graphs. The source for all graphs is Health Affairs, 32, no. 1 (2013):87-99)

What Healthcare Spending Went For:


Where Healthcare Spending Funds Came From:
Three highlights from the Health Affairs article are:

  • The distribution of healthcare spending for various services and providers has been relatively constant despite significant growth in total and per capita spending. (See chart below)
  • Growth in hospital spending slowed in 2010 and 2011 after bumping up in 2009. (Y/Y increases were 6.7% in 2009, and 4.3% and 3.9% in 2010 and 2011, compared to 3.9% for total National Health Expenditures for each of these years over the prior year.) The Health Affairs article notes that “The growth in use of hospital services remains low, with the number of inpatient days declining by 1.1 percent in 2011, following a decline of 1.6 percent in 2010, and the number of outpatient visits increasing by 0.7 percent, a slowdown from the increase of 1.5 percent in 2010.”
  • The percentages of healthcare spending coming from private businesses and households has decreased. This probably reflects higher government spending for the new Medicare prescription drug benefit and increased Medicaid enrollment during the economic downturn being only partially offset by private insurers shifting costs to individuals.

Effects of Health Reform (ACA)

While only a few of the ACA’s provisions went into effect during 2010 and 2011, there has been much speculation as to how (and how much) the ACA has or will change healthcare spending.  The Health Affairs article includes data about changes in private insurance enrollment from the requirement that companies offer coverage for dependents up to age 26. But it also points out that this age group is relatively inexpensive to insure so it probably didn’t produce great changes in spending.  However, Medicaid coverage and spending did change significantly, with more people in Medicaid programs due to the economic downturn, and the states’ costs increasing with the end of the temporary bump in Federal matching rates.

The Health Affairs authors don’t speculate about is how healthcare providers and organizations are shifting their operations and attitudes in anticipation of various of various new Federal programs, such as the Shared Savings Program for ACOs, value based payments, EMR Meaningful Use incentives/penalties, and penalties for avoidable adverse events. With private payers expanding clinical and economic accountability for healthcare providers through various payment innovations that are aligned with Medicare’s policies, the acceleration of system-wide transformations may be greater than projected – and lead to greater and earlier cost savings.  I have written about the factors that may be moderating healthcare spending growth, and believe that the relatively slower rate in hospital spending  and inpatient days reported in the Health Affairs article are the leading edge of this trend.  However, as hospitals purchase physician practices they may establish local market power that limits competition, and the prices charged to Medicare by these acquired practices could increase as they shift from the category of clinicians’ office to hospital outpatient facilities. Conversely, to the extent that these integrated healthcare systems assume risk for savings and quality performance – probably with payments involving episodes or bundles of care – then these concerns will be diminished, although not eliminated if they can still limit price and quality competition and comparisons.

Looking Forward to Future Health Spending

The Health Affairs article speculates a bit about where healthcare spending is heading in the near future. And, as is typical when trying to predict the future, the article doesn’t completely agree with what others have written. Not to be critical of the Health Affairs authors, (or professionals at the Congressional Budget Office or other organizations), but modeling is hard. To illustrate how difficult this task is – and how it can lead to different predicted outcomes even with lots of historical data to work with – below is a map showing the multiple predicted paths for 2012 Hurricane Sandy.

Communicating the meaning of the latest data can also be confusing. For example, the New York Times and the Wall Street Journal delivered significantly different verdicts on the meaning of the Health Affairs article. The Times’ headline declared, “Growth of Health Spending Stays Low” and quoted the Medicare agency’s chief actuary as saying “’I am optimistic.  There’s lot of potential.  More and more health care providers understand that the future cannot be like the past, in which health spending almost always grew faster than the gross domestic product.’”  Conversely, the Journal’s headline was “Health-Cost Pause Nears End,” and the article noted that the Health Affairs article, “…showed that the amount of spending to treat individuals, as opposed to spending on administration and insurance premiums, began to rise in 2011.” It then concluded that this was “signaling that cutbacks in health spending hadn’t become permanent.”

Predicting the Future is Easy

Predicting the future is easy. Accurately predicting the future is difficult. 2014 will almost certainly bring significant changes to how many people in the US get health insurance, how healthcare organizations deliver care, and how Medicare and Medicaid operate.  Like CMS’ chief actuary, I am optimistic, even though I also recognize that he is also correct in that, “The jury is still out whether all the innovations we’re testing will have much impact.” But I also see his actuarial caution as a reason for optimism because I believe that modeling based upon few precedents causes projections to be overly cautious, which should mean that actual savings will be greater than expected.

Jimmy Buffett Medicare and Healthcare

The title of Jimmy Buffett’s song “Changes in Latitudes, Changes in Attitudes” is a good description of the fundamental changes occurring in the US healthcare system:  Within the Federal Government – and Medicare in particular – widespread “Changes in Latitudes, Changes in Attitudes” are evident in the implementation of the Affordable Care and HITECH Acts, and the overall leadership of the Department of Health and Human Services.  Healthcare leaders in private organizations – and state and local governments – are embracing these changes, which collectively are leading to better healthcare quality and lower costs…. Or at least slower increases in healthcare costs, a.k.a. a bending of the healthcare cost curve.

Changes in Attitude

Traditionally government programs have worked at a long-arms distance from private companies and organizations.  For Medicare, this has meant that changes in rules and regulations were conveyed to healthcare providers and clinicians by publishing them in the Federal Register or as updates to the manuals used by Medicare’s bill-paying contractors. Private payers, (e.g. insurance companies), responded to these changes and updates because Medicare is the largest single payer for healthcare services. Providers and clinicians were thus always responding to a shifting quilt of payment rules and provisions – and more recently an additional layer of quality reporting requirements.

CMS and HHS have repositioned the government’s payment practices to serve an aligning leadership role that is minimizing confusion and complexity for providers and clinicians, while also promoting greater transparency and accountability. The government has accomplishing this by working with private payers (to the extent allowable by sunshine and antitrust laws) to give providers and clinicians more consistent guidance on payment policies and quality metrics, as well as incentives for improving the organization and delivery of care.  An example of this is the Comprehensive Primary Care Initiative (CPCI). The goal of this program is to promote higher quality patient-centric primary care. To determine the CPCI locations, CMS used a bidding process where the seven winning regions were those that committed the highest concentration of insured people, i.e., a combination of private payer, Medicaid, and Medicare covered lives. All the payers in the selected locations agreed to work collaboratively to identify the primary care practices that would get incentive payments for improving the quality and the integration of care – with each payer determining the specific level of financial incentives and support for each of their covered lives in these practices.

The key facets for the CPCI program are:

  • Public and private sector payers are truly aligned for comprehensive healthcare transformation.
  • It is using market forces to promote this transformation.
  • It is a community based initiative that is engaging local leaders, and which requires their buy-in and shared ownership of the process and the outcome.
  • It is structured to seek both quality improvements and costs savings.

Other initiatives from the ACA-created CMS Innovation Center are seeking to partner Medicare with local providers and payers for payment mechanisms that will promote better quality and lower costs, i.e. higher value healthcare that achieves the improvements that people and communities want.  Some of these programs involve bundling of payments around certain conditions, and the Innovation Center has explicitly stated a desire to consider providers’ ideas for new models of care and financing outside of the matrix of models it has already proposed.  (It is doing this through Health Care Innovation Awards.)

At the same time, “regular” Medicare is shifting its attitude about poor quality care. For example, last fall new Medicare rules became effective that prohibit hospitals from receiving a second payment from Medicare if a patient with pneumonia, congestive heart failure, or after a heart attack is readmitted to a hospital within 30 days, i.e. a return to the hospital that is preventable with good post-discharge care coordination and follow-up. This is just one of many new financial incentives – both positive and negative – involving actual quality of care that Medicare is moving forward with based upon various provisions of the ACA. (Private payers are implementing similar quality of care related payment policies.)

Changes in Latitude

While Jimmy Buffet was talking about geographic lines of latitudes, Medicare and HHS have exhibited changes in latitude for the requirements placed on many healthcare providers and clinicians – particularly those participating in programs designed to deliver higher quality care.  In addition to the Innovation Center examples cited above, Medicare’s new Shared Savings Program enables Accountable Care Organizations (ACO) to be structured in a wide variety of ways as long as they meet certain requirements and commitments.  And one area where they are permitted full autonomy is how an ACO distributes any shared savings (or other financial incentives) to the healthcare professionals and provider groups within or connected to the ACO.  While Medicare wants to be informed about these internal incentive structures – presumably to guide the development of future value-promoting programs – Medicare is not dictating this crucial facet of an ACO’s operations.

This attitude for considering such wide latitude of ideas illustrates the sea-change shift that has occurred within the government bureaucracy that has traditionally sought to evaluate “new ideas” primarily by comparing differences in existing care delivery models across the spectrum of the US healthcare system. However, CMS’ Innovation Center does not have full autonomy for conducting Medicare demonstration projects since it is required to focus on new models for paying healthcare providers, e.g., doctors and hospitals.  Because of this limitation (and related anti-kickback laws) the Innovation Center cannot do demonstrations that alter benefit structures, or empower ACOs to create new financial incentives for patients by changing co-payments or other cost sharing requirements. In contrast, private payers are implementing financial incentives to prompt patients to use certain providers, select primary care physicians to help guide them through complex care situations, or adhere to medical therapies for chronic conditions, etc. Perhaps in the future, (either directly or as part of the latitude for accountable healthcare systems), Medicare will be able to test modifications of beneficiaries’ cost-sharing to expand how patients are engaged for improving the quality of care and sharing cost savings.

Storms Ahead

While the changes occurring within CMS, private payers, and healthcare deliver organizations across the country are very exciting and have great potential, not every initiative or transformation will be 100% successful.  This is to be expected, and it will present the opportunity to learn from whatever shortfalls occur – as well as organizations that exceed expectations.  This knowledge will be important for creating new initiatives and modifying existing ones as they move forward.  Hopefully, other organizations committed to improving care and lowering costs in the public’s interest will be on board with CMS’ new attitude, support the inevitable challenges that law ahead, and seek to calm the waters of public discourse rather than whip the storms like Thor.

Accomplishments v. Activity in Healthcare

The phrase “Paying for Value not Volume” has been health reform’s mantra for several/many years.  But the concepts embodied in “Paying for Value not Volume” are problematic on two levels.  First, the term “Value not Volume” doesn’t convey a clear picture of the specific changes health reform is trying to achieve. This creates problems communicating the benefits of health reform and healthcare transformation to people who are not steeped in health policy, including most clinicians and patients.

And second, the “Paying for” part of the phrase indicates that the focus is on financial reforms. This creates a barrier to people (i.e., patients) embracing the underlying principles of “Value not Volume” because, from their perspective, changing how doctors and hospitals are paid seems unlikely to benefit them – and could potentially harm them by decreasing access or increasing their costs.  In addition, “Paying for Value not Volume” seems disconnected from the important access and clinical improvements that people care about as much as they care about cost control – if not more so.

Accomplishments Trumps Value
Therefore, rather than “Value not Volume” a better phrase would be “Accomplishments not Activity.” This phrase more directly represents what people and society really want from health reform, i.e. accomplishments in the form of better clinical and economic outcomes.

While it could be argued that “Value” captures the same intent as “Accomplishments,” “Value” is more ambiguous and less specific. For example, employees are often paid partially on the value they deliver for their company, but the specific factors used to determine that “value” are quantifiable measures such as sales or actions that produce revenue generating goods or services.

Thus, paying for healthcare accomplishments is a simpler and more direct concept. It avoids the rhetorical and cognitive extra step of translating “value” into specific accomplishments. In addition, the concept of paying for accomplishments could also include incentivizing patients for specific achievements related to improving their health or reducing their risk of illness.  In this way, “Paying for Accomplishments” is a broader term than “Paying for Value” because it connects innovations in provider and clinician payments to the expanding array of new provisions health insurance plans are adopting to motivate and help individuals achieve certain wellness goals, e.g., smoking cessation classes, weight loss incentives, etc.

Goals of Health Reform
Similarly, “Achieving Accomplishments” could be a good phrase for describing the goals of health reform, e.g., “The goal of health reform is to achieve accomplishments in three areas: improving health for populations, improving health care quality, and lowering health costs. And the accomplishments we expect to achieve this year for our [community, region, state, country] are……”

Conclusion
“Accomplishments not Activity” is a term that people can more easily understand, and this greater understanding could help the public embrace innovative payment models and insurance plan designs that – by rewarding accomplishments – are creating linked incentives for providers, clinicians, patients, and communities to collaboratively build higher performing healthcare delivery systems.