Attend any healthcare conference and you’ll quickly discover that it’s become downright accepted for healthcare leaders to chat about their steadfast commitment to “value-based care.”
The discussion 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 giving 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 similar to 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 lower 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 uncomplaining care (beyond the industry conference jargon and academic expositions on the subject)?
I got the idea for this column after a recent call taking into consideration a close professor buddy who has long been a lover of value-based care. On our call, he expressed dismay at his mother’s care in a value-based medical help that was contracted as soon as her Medicare Advantage plan.
On one occasion, his mom was discharged from a hospital sooner than he felt she should have been (she was later readmitted). On complementary occasion, she was denied permission to a tertiary cancer center, where he believed she should have subsequently for a second opinion. And upon a third occasion, she was denied entrance to a specialist who my buddy felt could have corrected an earlier, botched cataract surgery.
As my buddy decried his mother’s care experience, I couldn’t help but think that he (and others) are somehow failing to be unventilated to the dots in the midst of the concurrence of value-based care and its real-world implications. Which got me thinking that it perhaps might be helpful for anything of us to see closely at what value-based care means—good and bad—for patients receiving care governed by its principles.
These remarks arise from my grow 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 plan that partners contiguously with many value-based groups.
Tracking Hospital
While pharmaceutical costs gain a lot of attention, the single most costly line item for many groups full of life in the “value-based care” space is government 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 obsession of tracking hospital bed days (bed days/1,000 patients) and entrйe 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 next to managing patients in outpatient clinics and sometimes directly admitting patients to bright nursing facilities, whose costs are significantly demean than those of hospitals. Intensive outpatient dispensation often includes enhanced entrance to primary and urgent care and better running of chronic disease—all afterward the point of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups with make house calls to patients. The more technologically-enabled ones remotely monitor patients at particularly high risk of hospitalization.
Such uncompromising bed day supervision often translates into degrade hospitalization rates and condensed 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 snappishly to their homes with home care facilities or to skilled-nursing facilities in lieu of an new few nights in the hospital.
In addition, many value-based care groups prioritize pain-relieving care and proactively transition patients to hospice—in part, because it’s often the right event to do, and in part because patients afterward end-stage conditions often gain admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes mood that their doctors are increase of rate them by the side of the alleyway of palliative care and hospice prematurely, when they themselves have a desire to save fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with all of its joined tests and investigative procedures—can be expensive. In fee-for-service environments, primary care physicians often speak 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 lead in the hands of confident generalist primary care physicians who accept more answerability for patients and their outcomes than those who comport yourself in established primary care models. These generalist doctors only lecture to to specialists later than they habit an innovative opinion or the tolerant requires a procedure that they aren’t nimble to feign themselves.
Of course, there can be a downside. Patients who belong in the hands of specialists are sometimes delayed getting there—and can torment yourself and have poor outcomes hence of those delays. Because of the focus upon gatekeeping, patients often find themselves exasperated 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 unaccompanied ones complaining. Almost every practicing doctor will tell you stories about how much conduct yourself it sometimes takes to obtain praise for referrals that are absolutely necessary and just make common sense.
Relationships
Many value-based care groups contract considering narrow networks of specialists and medical centers. Members of these networks are usually agreed because they have relationships with the primary care groups and are sometimes employed members of their group (as subsequently Kaiser Permanente).
Increasingly, groups are using network reasoned tools like Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and careful about their use of reasoned tests and procedures.
The service of these kinds of networks are manifold. Groups purposefully curate specialists who communicate and coordinate effectively gone 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 scrap book systems that can more seamlessly help care coordination and the flow of tolerant information across clinical sites.
The downside is that some value-based networks are so focused on cost admin that they tend to contract later than specialists and hospitals based more on cost than on quality. Many “value-based” groups seem to steer clear of contracting subsequent to the most reputable (and sometimes unconventional quality) hospitals and their allied physician groups because they are expensive. Patients used to going to everything facility they gone for care are often amazed at how narrow the offerings are within their networks, especially in the unfortunate circumstances subsequently patients tend to intend out extremely 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 edit costs, many value-based care groups often introduce supplementary types of clinicians in the care of patients. This is frequently known as “practicing at the top of the license.” In practice, it means groups supplement the comport yourself of physicians subsequently nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The accessory of these clinical practitioners can attach access to care and also enlarge outcomes gone they proceed as allowance of a team to more effectively coordinate the care of patients and govern their chronic conditions. The best value-based care groups have determined and effective rubrics for how all members of the clinical teams pretend together to help patients.
On the additional hand, patients who want to look physicians—or, sometimes, need to look physicians—often gain frustrated that admission 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 progress of the formularies they employ for the care of patients.
In practice, this means they tend to favor drugs with 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 humiliate 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 new drugs on formularies and are sometimes price-focused to the tapering off of ignoring vanguard cost drugs that can meaningfully put to rest patients’ suffering. The thesame can be said about innovative diagnostics and newer procedural interventions.
Value-based care groups can speedily find themselves at odds afterward their patients following their recommendations and treatment plans contradict what patients themselves learn fake their own research upon the best and most advanced course of decree 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 irritating to aspiration at the root cause of why someone is absorbing healthcare services, sometimes focus on non-traditional, non-medical interventions that improve outcomes though lowering the total cost of care for patients.
When I was at CareMore, our care presidency team taking into account procured a refrigerator for a uncomplaining who needed it to gathering his insulin, recognizing that without the refrigerator, the uncomplaining would likely land in the hospital with tall blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the story of buying an Apple iPod to soothe a long-suffering whose demonstration led him to the emergency room beyond 100 period 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 trying to access 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 house social determinants of health have fruitless to raise a fuss any meaningful healthcare tone or cost help to the programs.
What’s more, while many value-based care organizations (including two I have led) provide permission to gym benefits, transportation, food, and extra interventions expected to add together key drivers of health, the published literature does not Keep the notion that these help have a meaningful effect upon cost or the quality 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 total cost of care by ensuring that patients are healthier and are making judicious use of the healthcare system, many organizations spend significant computer graphics trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically accustom yourself payments for patients based on the sharpness of their illnesses. As a result, many value-based care organizations spend significant spirit documenting the intensity of illness—time some patients may quality takes away from actually caring for them. For example, some medical groups employ home-based “welcome visits” from third-party vendors separate from annual physicals. The want 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 anything of the medical conditions patients experience.
Yet as few would dispute, at their worst, these visits are sometimes agreed divorced from a patient’s care and assist exclusively to maximize the payments groups receive from payers. These types of visits are often regarded as non-value further overhead.
lowering the sum cost
As I explained to my friend who was concerned roughly his mother’s care, the untold bank account of value-based care is that lowering the total cost of care even though improving air necessarily means creating some abrasion for some patients some of the time. And taking into consideration this abrasion will inevitably come the feeling of a lawsuit of interest, real or imagined. The financial bottom-line of the doctor and his medical charity 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 issue as a clear lunch.”
When a doctor denies a tolerant a test or supplementary drug or referral to a specialist, is it because we are in goal of fact optimizing the care of the patient?
Or is it because we are optimizing the economics of the value-based group?
In an era like 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 beast made to optimize care or to protect quarterly earnings?
Said complementary way, is the close term perform focused upon the cost allowance of the famed value equation? Or the tone portion?
It’s not always simple to know.
This set of questions and explanation should not be admittance 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 pro to patients. Nor should it be entrance as a reprove of value-based care.
But with whatever of the optimistic fanfare (a small portion of which I, too, am guilty of generating) must furthermore 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 accomplish 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 rasping practices to rule costs are pursued through the lens of legal benefit to the patient, not the financial interests of the group. The comings and goings to which we subject patients must be guided by the “radical common sense” that all one of us would desire to see in do its stuff for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we recognize to erode the most pretentious asset we have in the American healthcare system: the trust of the people we serve.
