Attend any healthcare conference and you’ll speedily discover that it’s become downright fashionable for healthcare leaders to chat about their unwavering commitment to “value-based care.”
The aeration 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 literary 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 dispensation 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 the same way as 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 demean cost of care for a population of patients, while aiming to add up outcomes.
But what does this value-based care see like in practice in the real-world of tolerant care (beyond the industry conference jargon and academic expositions upon the subject)?
I got the idea for this column after a recent call later a near professor buddy who has long been a aficionado of value-based care. On our call, he expressed dismay at his mother’s care in a value-based medical bureau that was contracted as soon as her Medicare Advantage plan.
On one occasion, his mommy was discharged from a hospital sooner than he felt she should have been (she was higher readmitted). On out of the ordinary occasion, she was denied access to a tertiary cancer center, where he believed she should have subsequently for a second opinion. And on a third occasion, she was denied access to a specialist who my buddy felt could have corrected an earlier, botched cataract surgery.
As my friend decried his mother’s care experience, I couldn’t back but think that he (and others) are someway failing to link up the dots amongst the deal of value-based care and its real-world implications. Which got me thinking that it perhaps might be long-suffering for everything 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 period 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 goal that partners alongside with many value-based groups.
Tracking Hospital
While pharmaceutical costs get a lot of attention, the single most expensive line item for many groups functional in the “value-based care” space is management of acute hospital bed days. A day 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 craving of tracking hospital bed days (bed days/1,000 patients) and entry rates (admissions/1,000 patients) on a daily basis. The humiliate the numbers the better.
The overall purpose is to attempt to avoid hospitalizations by next door to managing patients in outpatient clinics and sometimes directly admitting patients to clever nursing facilities, whose costs are significantly demean than those of hospitals. Intensive outpatient management often includes enhanced admission to primary and urgent care and better government of chronic disease—all next the object of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups then make house calls to patients. The more technologically-enabled ones remotely monitor patients at particularly high risk of hospitalization.
Such scratchy bed day dispensation often translates into belittle hospitalization rates and condensed hospitalizations, but it can sometimes depart patients and families feeling immediate and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be surprised when they’re discharged hurriedly to their homes with house care services or to skilled-nursing facilities in lieu of an additional 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 event to do, and in ration because patients next end-stage conditions often get admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes atmosphere that their doctors are quickening them next to the lane of palliative care and hospice prematurely, when they themselves have a want to keep fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with everything of its associated tests and logical procedures—can be expensive. In fee-for-service environments, primary care physicians often adopt 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 plus in the hands of confident generalist primary care physicians who take more answerability for patients and their outcomes than those who piece of legislation in established primary care models. These generalist doctors only take up to specialists once they craving an advanced opinion or the compliant requires a procedure that they aren’t skilled to action themselves.
Of course, there can be a downside. Patients who belong in the hands of specialists are sometimes delayed getting there—and can dwell on and have destitute outcomes in view of that of those delays. Because of the focus upon 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 analytical tests. And patients aren’t the by yourself ones complaining. Almost all practicing doctor will say you stories not quite how much statute it sometimes takes to obtain praise for referrals that are absolutely necessary and just make common sense.
Relationships
Many value-based care groups contract following narrow networks of specialists and medical centers. Members of these networks are usually fixed because they have contact with the primary care groups and are sometimes employed members of their group (as later than Kaiser Permanente).
Increasingly, groups are using network methodical tools as soon as Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and cautious about their use of reasoned tests and procedures.
The help of these kinds of networks are manifold. Groups intentionally curate specialists who communicate and coordinate effectively bearing in mind 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 see for….?”). And these specialists often operate upon common electronic health scrap book systems that can more seamlessly serve care coordination and the flow of long-suffering information across clinical sites.
The downside is that some value-based networks are in view of that focused upon cost admin that they tend to contract taking into consideration specialists and hospitals based more on cost than upon quality. Many “value-based” groups seem to steer positive of contracting considering the most reputable (and sometimes higher quality) hospitals and their joined physician groups because they are expensive. Patients used to going to all facility they when for care are often amazed at how narrow the offerings are within their networks, especially in the unfortunate circumstances taking into account patients tend to wish out severely specialized care facilities (i.e. cancer centers) and specialists.
In addition, some patients find 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 further 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 supplement the accomplishment of physicians taking into consideration nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The addition of these clinical practitioners can attach access to care and also count outcomes next they pretense as allowance of a team to more effectively coordinate the care of patients and run their chronic conditions. The best value-based care groups have sure and in force rubrics for how whatever members of the clinical teams take effect together to benefits patients.
On the new hand, patients who want to see physicians—or, sometimes, need to see physicians—often get frustrated that right of entry to generalist physicians (and specialists) might be limited by non-physician gatekeepers. What’s more, the worst value-based care groups use professionals of everything types interchangeably without paying close attention to differences in skills and knowledge across clinician types—or articulating a clear 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 spread of the formularies they hire for the care of patients.
In practice, this means they tend to favor drugs considering 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 demean drug costs and a focus upon 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 supplementary drugs on formularies and are sometimes price-focused to the tapering off of ignoring vanguard cost drugs that can meaningfully assuage patients’ suffering. The thesame can be said about liberal diagnostics and newer procedural interventions.
Value-based care groups can quickly find themselves at odds in the freshen of their patients afterward their recommendations and treatment plans contradict what patients themselves learn take effect their own research upon the best and most modern 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 on non-traditional, non-medical interventions that attach outcomes while lowering the total cost of care for patients.
When I was at CareMore, our care processing team gone procured a refrigerator for a long-suffering who needed it to stock his insulin, recognizing that without the refrigerator, the long-suffering would likely home in the hospital with tall blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the bill of buying an Apple iPod to soothe a long-suffering whose campaigning led him to the emergency room beyond 100 era 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 a pain to right of entry 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 residence social determinants of health have unproductive to disturb any meaningful healthcare feel or cost help to the programs.
What’s more, while many value-based care organizations (including two I have led) provide right of entry to gym benefits, transportation, food, and supplementary interventions meant to affix key drivers of health, the published literature does not maintain the notion that these support have a meaningful effect on cost or the mood of outcomes—though the effect on select individual patients is incontrovertible.
Revenue Focused?
While in its purest form, value-based healthcare is very nearly lowering the sum cost of care by ensuring that patients are healthier and are making judicious use of the healthcare system, many organizations spend significant life trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically adapt payments for patients based upon the severity of their illnesses. As a result, many value-based care organizations spend significant enthusiasm documenting the intensity of illness—time some patients may air takes away from actually caring for them. For example, some medical groups employ home-based “welcome visits” from third-party vendors turn your back on annual physicals. The intend of these visits is not at all clear to patients. But for the medical groups, these “welcome visits” identify unmet medical needs and put into action appropriate referrals, while enabling groups to document all of the medical conditions patients experience.
Yet as few would dispute, at their worst, these visits are sometimes totally divorced from a patient’s care and facilitate exclusively to maximize the payments groups receive from payers. These types of visits are often regarded as non-value other overhead.
lowering the sum cost
As I explained to my friend who was concerned very nearly his mother’s care, the untold tab of value-based care is that lowering the sum cost of care while improving vibes necessarily means creating some abrasion for some patients some of the time. And like this abrasion will inevitably come the feeling of a achievement of interest, real or imagined. The financial bottom-line of the doctor and his medical intervention may sometimes go next to the care that the accommodating feels he or she needs. As my late economics teacher, Martin S. Feldstein, often said, “There’s no such thing as a forgive lunch.”
When a doctor denies a uncomplaining a exam or supplementary drug or referral to a specialist, is it because we are in reality optimizing the care of the patient?
Or is it because we are optimizing the economics of the value-based group?
In an era similar to 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 extra pharmaceutical inborn made to optimize care or to guard quarterly earnings?
Said complementary way, is the close term acquit yourself focused upon the cost allowance of the famed value equation? Or the tone portion?
It’s not always easy to know.
This set of questions and explanation should not be approach as a excuse 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 open as a caution of value-based care.
But with all of the optimistic fanfare (a little portion of which I, too, am guilty of generating) must as a consequence come a dose of realism. Value-based care can indeed be an solution to some of what ails American healthcare, but at its inauguration there must be something somewhat increasingly quaint and elusive:
An ethical underpinning to always reach 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 severe practices to run costs are pursued through the lens of real benefit to the patient, not the financial interests of the group. The undertakings to which we subject patients must be guided by the “radical common sense” that every one of us would want to look in do its stuff for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we put taking place with to erode the most artificial asset we have in the American healthcare system: the trust of the people we serve.
