Attend any healthcare conference and you’ll quickly discover that it’s become downright accepted for healthcare leaders to talk about their immovable commitment to “value-based care.”
The a breath of lively 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 theoretical 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 presidency 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 next the intent of bringing value-based care to the masses.
And big-box retailers such as CVS, Walgreens, and Walmart, too, have jumped upon the value bandwagon.
The underlying principle of “value-based care” is easy enough—managing to a degrade cost of care for a population of patients, while aiming to supplement outcomes.
But what does this value-based care see like in practice in the real-world of patient care (beyond the industry conference jargon and academic expositions upon the subject)?
I got the idea for this column after a recent call similar to a close professor buddy who has long been a aficionada of value-based care. On our call, he expressed dismay at his mother’s care in a value-based medical bureau that was contracted behind her Medicare Advantage plan.
On one occasion, his mom was discharged from a hospital sooner than he felt she should have been (she was complex readmitted). On out of the ordinary occasion, she was denied entrance to a tertiary cancer center, where he believed she should have once for a second opinion. And on a third occasion, she was denied admission 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 urge on but think that he (and others) are somehow failing to affix the dots in the middle of the covenant of value-based care and its real-world implications. Which got me thinking that it perhaps might be compliant for whatever of us to look closely at what value-based care means—good and bad—for patients receiving care governed by its principles.
These notes arise from my become old 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 ambition that partners next to with many value-based groups.
Tracking Hospital
While pharmaceutical costs gain a lot of attention, the single most expensive line item for many groups functional in the “value-based care” space is meting out of acute hospital bed days. A hours of daylight in the hospital can cost as much as $3,000-$4,000. Given these hefty cost implications of a single hours of daylight in the hospital, leaders of many value-based care organizations are in the habit of tracking hospital bed days (bed days/1,000 patients) and door rates (admissions/1,000 patients) on a daily basis. The humiliate the numbers the better.
The overall plan is to attempt to avoid hospitalizations by nearby managing patients in outpatient clinics and sometimes directly admitting patients to talented nursing facilities, whose costs are significantly subjugate than those of hospitals. Intensive outpatient processing often includes enhanced entrance to primary and urgent care and better presidency of chronic disease—all later the aspire of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups furthermore make house calls to patients. The more technologically-enabled ones remotely monitor patients at particularly tall risk of hospitalization.
Such harsh bed day presidency often translates into subjugate hospitalization rates and abbreviated hospitalizations, but it can sometimes leave patients and families feeling gruff and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be surprised when they’re discharged rapidly to their homes with house care facilities or to skilled-nursing services in lieu of an new few nights in the hospital.
In addition, many value-based care groups prioritize numbing care and proactively transition patients to hospice—in part, because it’s often the right situation to do, and in allocation because patients subsequently end-stage conditions often get admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes setting that their doctors are hurrying them next to the lane of deadening care and hospice prematurely, when they themselves have a want to save fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with whatever of its joined tests and analytical procedures—can be expensive. In fee-for-service environments, primary care physicians often take up 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 pretense in conventional primary care models. These generalist doctors only adopt to specialists like they obsession an open-minded opinion or the tolerant requires a procedure that they aren’t dexterous to perform 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 destitute outcomes correspondingly of those delays. Because of the focus upon gatekeeping, patients often find themselves annoyed by utilization management—the administrative process through which health plans and medical groups review referrals to specialists and orders for systematic tests. And patients aren’t the lonely ones complaining. Almost all practicing doctor will tell you stories very nearly how much produce a result it sometimes takes to obtain approval for referrals that are absolutely critical and just make common sense.
Relationships
Many value-based care groups contract next narrow networks of specialists and medical centers. Members of these networks are usually chosen because they have dealings with the primary care groups and are sometimes employed members of their group (as in the same way as Kaiser Permanente).
Increasingly, groups are using network rational tools as soon as Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and careful about their use of methodical tests and procedures.
The service of these kinds of networks are manifold. Groups carefully 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 on common electronic health autograph album systems that can more seamlessly relief care coordination and the flow of accommodating information across clinical sites.
The downside is that some value-based networks are therefore focused upon cost government that they tend to contract in the spread of specialists and hospitals based more on cost than upon quality. Many “value-based” groups seem to steer certain of contracting when the most reputable (and sometimes future quality) hospitals and their associated physician groups because they are expensive. Patients used to going to anything facility they gone for care are often amazed at how narrow the offerings are within their networks, especially in the unfortunate circumstances behind patients tend to goal out extremely 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 additional 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 put on an act of physicians like nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The addition of these clinical practitioners can insert access to care and also adjoin outcomes when they do something as share of a team to more effectively coordinate the care of patients and manage their chronic conditions. The best value-based care groups have positive and lively rubrics for how everything members of the clinical teams undertaking together to bolster patients.
On the other hand, patients who want to look physicians—or, sometimes, need to look physicians—often gain frustrated that permission to generalist physicians (and specialists) might be limited by non-physician gatekeepers. What’s more, the worst value-based care groups use professionals of anything 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 take forward of the formularies they employ for the care of patients.
In practice, this means they tend to favor drugs similar to 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 lower 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 extra drugs upon formularies and are sometimes price-focused to the point of ignoring cutting edge cost drugs that can meaningfully calm patients’ suffering. The similar can be said about campaigner diagnostics and newer procedural interventions.
Value-based care groups can speedily find themselves at odds once their patients taking into account their recommendations and treatment plans contradict what patients themselves learn piece of legislation their own research on the best and most forward looking course of perform for their condition.
Pro Non-Medical Interventions
Many groups that are “value-based” assume full responsibility (often known as “full risk”) for the sum cost of care. These groups, which are known for trying to goal at the root cause of why someone is consuming healthcare services, sometimes focus on non-traditional, non-medical interventions that tally outcomes though lowering the total cost of care for patients.
When I was at CareMore, our care direction team gone procured a refrigerator for a patient who needed it to accretion his insulin, recognizing that without the refrigerator, the patient would likely estate in the hospital with tall blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the tab of buying an Apple iPod to soothe a tolerant whose nervousness led him to the emergency room on top of 100 mature 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 infuriating to admission 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 domicile social determinants of health have fruitless to protest any meaningful healthcare quality or cost improvement to the programs.
What’s more, while many value-based care organizations (including two I have led) provide entry to gym benefits, transportation, food, and extra interventions expected to put in key drivers of health, the published literature does not maintain the notion that these relief 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 approximately 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 vivaciousness trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically acclimatize payments for patients based on the sharpness of their illnesses. As a result, many value-based care organizations spend significant vibrancy documenting the sharpness of illness—time some patients may atmosphere takes away from actually caring for them. For example, some medical groups employ home-based “welcome visits” from third-party vendors keep apart from annual physicals. The goal of these visits is not at all determined to patients. But for the medical groups, these “welcome visits” identify unmet medical needs and motivate appropriate referrals, while enabling groups to document everything 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 benefits exclusively to maximize the payments groups get from payers. These types of visits are often regarded as non-value bonus overhead.
lowering the total cost
As I explained to my friend who was concerned approximately his mother’s care, the untold report of value-based care is that lowering the total cost of care even if improving character necessarily means creating some abrasion for some patients some of the time. And later this abrasion will inevitably come the feeling of a charge of interest, real or imagined. The financial bottom-line of the doctor and his medical group may sometimes go neighboring the care that the patient feels he or she needs. As my late economics teacher, Martin S. Feldstein, often said, “There’s no such issue as a release lunch.”
When a doctor denies a compliant a test or other drug or referral to a specialist, is it because we are really optimizing the care of the patient?
Or is it because we are optimizing the economics of the value-based group?
In an era later 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 new pharmaceutical instinctive made to optimize care or to protect quarterly earnings?
Said choice way, is the close term be in focused on the cost part of the famed value equation? Or the atmosphere portion?
It’s not always easy to know.
This set of questions and interpretation should not be admittance as a explanation of the costly, traditional fee-for-service system, which has its own skew towards over-delivering care, often with Tiny to no plus to patients. Nor should it be read as a warn about of value-based care.
But with anything of the optimistic fanfare (a little portion of which I, too, am guilty of generating) must in addition to come a dose of realism. Value-based care can indeed be an answer 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 harsh practices to manage costs are pursued through the lens of authenticated 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 all one of us would want to look in put-on for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we agree to to erode the most exaggerated asset we have in the American healthcare system: the trust of the people we serve.
