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Editor's Note
May 2015

Valuing Our Patients’ Preferences

JAMA Intern Med. 2015;175(5):853. doi:10.1001/jamainternmed.2015.126

It makes sense to pay for value. By paying hospitals and physicians more for higher-value outcomes rather than more for doing more things, we are likely to improve the health of our patients as well as the financial health of our system. The challenge is identifying measurable outcomes that represent high-value health care.

On the surface, it makes sense to reward hospitals that have lower mortality rates for a given condition, such as pneumonia. But, as shown by Stefan and colleagues,1 issues in health policy are often more complicated than they initially appear. The authors found that pneumonia played a major role in the death of only 18.3% of patients. For 81.7% of patients, pneumonia was a minor contributor in that the patient had “advanced life-threatening illnesses (ie, met criteria for palliative care) and pneumonia was on the final pathway to death.”1 Indeed, 57.6% of these patients had a do-not-resuscitate or do-not-intubate order on admission. For these patients, the usual process measures for pneumonia treatment would not likely be relevant. Instead, the most patient-centered outcomes, and the ones we would want the system to focus on, would likely be end-of-life planning, pain control, and spiritual counseling. Paying hospitals for lower mortality rates could create a perverse incentive for hospitals to aggressively treat elderly patients with multiple comorbidities, even if the patients’ wishes were for more of a focus on comfort.