Attend any healthcare conference and you’ll quickly discover that it’s become downright fashionable for healthcare leaders to chat about their unbending commitment to “value-based care.”
The a breath of vivacious air has become ubiquitous in healthcare circles. Its virtuousness goes unchallenged.
Unwavering Commitment to “value-based care.”
Michael E. Porter and Elizabeth Teisberg (with whom I worked as a student and moot at Harvard Business School from 2006-2010) popularized the value equation (Value = Quality/Cost) and suggested that improving value should be any healthcare system leader’s highest aim.
Since that time, the federal dealing out has introduced a number of policy instruments to accelerate the transition to including Medicare Advantage, accountable care organizations, and bundled payment models.
New startups—such as Aledade, Iora Health, Landmark Health, Oak Street Health, and VillageMD—have arisen in imitation of the intent of bringing value-based care to the masses.
And big-box retailers such as CVS, Walgreens, and Walmart, too, have jumped on the value bandwagon.
The underlying principle of “value-based care” is easy enough—managing to a belittle cost of care for a population of patients, while aiming to put in outcomes.
But what does this value-based care look like in practice in the real-world of accommodating care (beyond the industry conference jargon and academic expositions on the subject)?
I got the idea for this column after a recent call later a near professor buddy who has long been a devotee of value-based care. On our call, he expressed dismay at his mother’s care in a value-based medical help that was contracted afterward her Medicare Advantage plan.
On one occasion, his mommy was discharged from a hospital sooner than he felt she should have been (she was vanguard readmitted). On choice occasion, she was denied right of entry to a tertiary cancer center, where he believed she should have afterward for a second opinion. And upon a third occasion, she was denied right of entry to a specialist who my friend felt could have corrected an earlier, botched cataract surgery.
As my buddy decried his mother’s care experience, I couldn’t back but think that he (and others) are someway failing to link up the dots in the midst of the conformity of value-based care and its real-world implications. Which got me thinking that it perhaps might be accepting for whatever of us to see closely at what value-based care means—good and bad—for patients receiving care governed by its principles.
These observations arise from my mature as an academic studying value-based care; my leadership of CareMore and Aspire Health, the value-based care delivery divisions of Anthem Inc; and my current role leading SCAN Health Plan, a non-profit Medicare Advantage health set sights on that partners next door to with many value-based groups.
Tracking Hospital
While pharmaceutical costs get a lot of attention, the single most costly line item for many groups working in the “value-based care” space is supervision of acute hospital bed days. A daylight in the hospital can cost as much as $3,000-$4,000. Given these hefty cost implications of a single daylight in the hospital, leaders of many value-based care organizations are in the obsession of tracking hospital bed days (bed days/1,000 patients) and edit rates (admissions/1,000 patients) on a daily basis. The lower the numbers the better.
The overall goal is to attempt to avoid hospitalizations by closely managing patients in outpatient clinics and sometimes directly admitting patients to gifted nursing facilities, whose costs are significantly humiliate than those of hospitals. Intensive outpatient handing out often includes enhanced entry to primary and urgent care and better executive of chronic disease—all as soon as the goal of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups after that make house calls to patients. The more technologically-enabled ones remotely monitor patients at particularly high risk of hospitalization.
Such sharp bed day running often translates into subjugate hospitalization rates and edited hospitalizations, but it can sometimes leave patients and families feeling rude and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be amazed when they’re discharged gruffly to their homes with home care services or to skilled-nursing services in lieu of an other few nights in the hospital.
In addition, many value-based care groups prioritize painkilling care and proactively transition patients to hospice—in part, because it’s often the right matter to do, and in ration because patients similar to end-stage conditions often gain admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes atmosphere that their doctors are hastening them the length of the pathway of pain-relieving care and hospice prematurely, when they themselves have a want to save fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with all of its associated tests and questioning procedures—can be expensive. In fee-for-service environments, primary care physicians often talk to patients reflexively. Chest pain? Cardiologist. Stomach pain? Gastroenterologist. Rash? Dermatologist. Aggressive specialty consultation is a mainstay for many fee-for-service primary care doctors.
In value-based care organizations, patients gain in the hands of confident generalist primary care physicians who take more answerability for patients and their outcomes than those who undertaking in normal primary care models. These generalist doctors only refer to specialists in the same way as they obsession an enlightened opinion or the accommodating requires a procedure that they aren’t competent to feat themselves.
Of course, there can be a downside. Patients who belong in the hands of specialists are sometimes delayed getting there—and can struggle and have poor outcomes suitably of those delays. Because of the focus on gatekeeping, patients often locate themselves enraged by utilization management—the administrative process through which health plans and medical groups review referrals to specialists and orders for critical tests. And patients aren’t the and no-one else ones complaining. Almost every practicing doctor will tell you stories roughly how much produce an effect it sometimes takes to obtain acclamation for referrals that are absolutely indispensable and just make common sense.
Relationships
Many value-based care groups contract in the way of being of narrow networks of specialists and medical centers. Members of these networks are usually prearranged because they have interaction with the primary care groups and are sometimes employed members of their group (as once Kaiser Permanente).
Increasingly, groups are using network reasoned tools past Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and cautious about their use of rational tests and procedures.
The help of these kinds of networks are manifold. Groups deliberately curate specialists who communicate and coordinate effectively as soon as primary care physicians and practice high-quality, evidence-based medicine. Group selection of specialists eliminates the guess-work that sometimes plagues patients (“Who should I look for….?”). And these specialists often operate upon common electronic health autograph album systems that can more seamlessly abet care coordination and the flow of tolerant information across clinical sites.
The downside is that some value-based networks are so focused upon cost government that they tend to contract taking into consideration specialists and hospitals based more upon cost than upon quality. Many “value-based” groups seem to steer distinct of contracting once the most reputable (and sometimes innovative quality) hospitals and their joined physician groups because they are expensive. Patients used to going to anything facility they subsequent to for care are often amazed at how narrow the offerings are within their networks, especially in the unfortunate circumstances subsequent to patients tend to aspire out very specialized care facilities (i.e. cancer centers) and specialists.
In addition, some patients locate that small, carefully curated specialist networks subject them to significant, potentially harmful delays in accessing care.
Reduce Costs
Again, seeking to reduce costs, many value-based care groups often introduce other types of clinicians in the care of patients. This is frequently known as “practicing at the summit of the license.” In practice, it means groups auxiliary the deed of physicians following nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The addition of these clinical practitioners can combine access to care and also append outcomes later than they fake as part of a team to more effectively coordinate the care of patients and govern their chronic conditions. The best value-based care groups have certain and keen rubrics for how whatever members of the clinical teams produce a result together to support patients.
On the additional hand, patients who desire to look physicians—or, sometimes, need to look physicians—often get frustrated that access to generalist physicians (and specialists) might be limited by non-physician gatekeepers. What’s more, the worst value-based care groups use professionals of whatever types interchangeably without paying close attention to differences in skills and knowledge across clinician types—or articulating a determined view as to how to coordinate efforts across disciplines.
lower drug costs
Value-based care groups that are managing to the cost/quality threshold are often quite conservative in the encroachment of the formularies they hire for the care of patients.
In practice, this means they tend to favor drugs once a significant evidence base and often prioritize the delivery of non-branded generic pharmaceuticals in lieu of branded drugs, and sometimes older drugs in lieu of newer drugs. What this translates to for price-sensitive patients is often subjugate drug costs and a focus on affordability of the therapies that they are prescribed.
That said, some critics argue that value-based organizations sometimes seem anti-innovation, as they can be slow to adopt additional drugs upon formularies and are sometimes price-focused to the narrowing of ignoring higher cost drugs that can meaningfully assuage patients’ suffering. The same can be said about avant-garde diagnostics and newer procedural interventions.
Value-based care groups can speedily find themselves at odds when their patients subsequent to their recommendations and treatment plans contradict what patients themselves learn doing their own research on the best and most ahead of its time course of play in for their condition.
Pro Non-Medical Interventions
Many groups that are “value-based” assume full responsibility (often known as “full risk”) for the total cost of care. These groups, which are known for grating to aim at the root cause of why someone is consuming healthcare services, sometimes focus upon non-traditional, non-medical interventions that append outcomes while lowering the sum cost of care for patients.
When I was at CareMore, our care meting out team with procured a refrigerator for a compliant who needed it to accrual his insulin, recognizing that without the refrigerator, the compliant would likely home in the hospital with tall blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the credit of buying an Apple iPod to soothe a long-suffering whose confrontation led him to the emergency room over 100 time a year. At SCAN, our Healthcare in Action medical group, which treats people experiencing homelessness, sometimes provides cell phones to patients; connectivity is important for people exasperating to entrance shelter housing.
Some people, hearing these exceptional stories, might argue that they are just that—stories—that don’t reflect their own experience of care. And few large-scale studies of interventions to quarters social determinants of health have failed to disturb any meaningful healthcare character or cost benefit to the programs.
What’s more, while many value-based care organizations (including two I have led) provide access to gym benefits, transportation, food, and new interventions expected to augment key drivers of health, the published literature does not preserve the notion that these foster have a meaningful effect on cost or the tone of outcomes—though the effect on select individual patients is incontrovertible.
Revenue Focused?
While in its purest form, value-based healthcare is not quite lowering the total cost of care by ensuring that patients are healthier and are making judicious use of the healthcare system, many organizations spend significant vibrancy trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically adapt payments for patients based on the severity of their illnesses. As a result, many value-based care organizations spend significant dynamism documenting the severity of illness—time some patients may vibes takes away from actually caring for them. For example, some medical groups employ home-based “welcome visits” from third-party vendors turn away from annual physicals. The objective of these visits is not at all clear to patients. But for the medical groups, these “welcome visits” identify unmet medical needs and activate appropriate referrals, while enabling groups to document anything of the medical conditions patients experience.
Yet as few would dispute, at their worst, these visits are sometimes extremely divorced from a patient’s care and utility exclusively to maximize the payments groups receive from payers. These types of visits are often regarded as non-value further overhead.
lowering the total cost
As I explained to my friend who was concerned more or less his mother’s care, the untold report of value-based care is that lowering the sum cost of care though improving setting necessarily means creating some abrasion for some patients some of the time. And gone this abrasion will inevitably come the feeling of a act of interest, real or imagined. The financial bottom-line of the doctor and his medical intervention may sometimes go neighboring the care that the tolerant feels he or she needs. As my late economics teacher, Martin S. Feldstein, often said, “There’s no such thing as a clear lunch.”
When a doctor denies a uncomplaining a test or extra drug or referral to a specialist, is it because we are truly optimizing the care of the patient?
Or is it because we are optimizing the economics of the value-based group?
In an era in imitation of many “value-based groups” are backed by venture capital, owned by private equity firms, or publicly traded, is the decision to deny a specialist referral or the latest supplementary pharmaceutical mammal made to optimize care or to guard quarterly earnings?
Said other way, is the close term sham focused on the cost allocation of the famed value equation? Or the quality portion?
It’s not always easy to know.
This set of questions and clarification should not be retrieve as a defense of the costly, traditional fee-for-service system, which has its own skew towards over-delivering care, often with little to no help to patients. Nor should it be way in as a rebuke of value-based care.
But with everything of the optimistic fanfare (a little portion of which I, too, am guilty of generating) must afterward come a dose of realism. Value-based care can indeed be an solution to some of what ails American healthcare, but at its creation there must be something somewhat increasingly quaint and elusive:
An ethical underpinning to always realize what’s right for the patient.
For value-based care to succeed, groups must have a robust clinical (and financial) culture in place to ensure that uncompromising practices to direct costs are pursued through the lens of authenticated benefit to the patient, not the financial interests of the group. The goings-on to which we subject patients must be guided by the “radical common sense” that all one of us would want to see in perform for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we take on to erode the most exaggerated asset we have in the American healthcare system: the trust of the people we serve.
