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Friday, August 01, 2014

Is "low value [medical] care like Justice's Stewart's definition of pornography?

In a 1964 obscenity case, Supreme Court Justice Potter Stewart admitted that he might not be able to specifically define the parameters of pornography but " I know it when I see it".

I wonder if a similar situation exists with the concept of low value medical care (LVC) which is  a main talking point in a campaign spearheaded by the American Board of Medicine Foundation (ABIMF).

Surely this term is not just a floating abstraction. I thought I had  simply missed the definition in reading about LVC. Off to Google to enter "definition of Low value care". Neither Google nor Bing lead me to a generally accepted definition of low value care or for that matter value in health care in general.

In fact the literature of health care value is bereft of a general consensus as described in this quote from Dr.Scott D. Ramsey writing in the Oncologist :

"one of the most enduring and controversial topics in medicine is the concept of what constituents value in health care"

The concepts of the business management  guru, Michael E. Porter are widely quoted and for him value is defined as "health outcome per dollar spent" but he spends considerable effort in explicating how elusive and difficult that is to put into meaningful operational use.

Given that the term value lacks a clear definition and defined operational boundaries, how did the American Board of Internal Medicine Foundation (ABIMF) expect many medical professional organization to conjure up a list of low value procedures? That initiative was part of their "Choosing Wisely " Campaign. Yet a list were generated  by some process or processes with some or other operational meaning of low value.I guest these medical thought leaders know it when they see it.

Professor Catherine MacClean of University of Pennsylvania gives this definition of low value health care, which seems to be close to if not on the mark and at least  is more substantive:

"any care for which there exists an alternative form of care this is both equally  effective and lower cost. In this regard no care or watchful waiting is eligible for the designation "alternative form" I wonder how many of the  "Choosing Wisely" campaign's wise choices  meet that definition.

 I think that more than a few writers who talk about low value care may be using  little more than Justice Stewart's ocular  technique.

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