Attend any healthcare conference and you’ll speedily discover that it’s become downright all the rage for healthcare leaders to talk about their stubborn commitment to “value-based care.”
The ventilation 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 speculative 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 running 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 considering 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 simple enough—managing to a humiliate cost of care for a population of patients, while aiming to attach 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 on the subject)?
I got the idea for this column after a recent call gone a close professor friend who has long been a enthusiast of value-based care. On our call, he expressed dismay at his mother’s care in a value-based medical intervention that was contracted next her Medicare Advantage plan.
On one occasion, his mommy was discharged from a hospital sooner than he felt she should have been (she was forward-thinking readmitted). On other occasion, she was denied entrance to a tertiary cancer center, where he believed she should have later for a second opinion. And on a third occasion, she was denied 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 up but think that he (and others) are somehow failing to link up the dots amid the union of value-based care and its real-world implications. Which got me thinking that it perhaps might be obliging 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 epoch 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 strive for 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 full of life in the “value-based care” space is presidency 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 morning in the hospital, leaders of many value-based care organizations are in the dependence of tracking hospital bed days (bed days/1,000 patients) and entrance rates (admissions/1,000 patients) on a daily basis. The demean the numbers the better.
The overall want is to attempt to avoid hospitalizations by next door to managing patients in outpatient clinics and sometimes directly admitting patients to gifted nursing facilities, whose costs are significantly demean than those of hospitals. Intensive outpatient running often includes enhanced right of entry to primary and urgent care and better organization of chronic disease—all bearing in mind the point toward of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups next make house calls to patients. The more technologically-enabled ones remotely monitor patients at particularly high risk of hospitalization.
Such aggressive bed day giving out often translates into degrade hospitalization rates and reduced hospitalizations, but it can sometimes depart patients and families feeling rushed and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be surprised when they’re discharged quickly to their homes with home care services or to skilled-nursing services in lieu of an extra 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 business to do, and in share because patients in the same way as end-stage conditions often gain admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes vibes that their doctors are rushing them next to the alleyway of deadening care and hospice prematurely, when they themselves have a desire to save fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with anything of its associated tests and questioning procedures—can be expensive. In fee-for-service environments, primary care physicians often attend 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 plus in the hands of confident generalist primary care physicians who accept more liability for patients and their outcomes than those who do its stuff in acknowledged primary care models. These generalist doctors only refer to specialists in imitation of they need an highly developed opinion or the tolerant requires a procedure that they aren’t dexterous to behave themselves.
Of course, there can be a downside. Patients who belong in the hands of specialists are sometimes delayed getting there—and can worry and have destitute outcomes thus of those delays. Because of the focus upon gatekeeping, patients often find themselves irritated by utilization management—the administrative process through which health plans and medical groups review referrals to specialists and orders for diagnostic tests. And patients aren’t the unaided ones complaining. Almost all practicing doctor will say you stories nearly how much feat it sometimes takes to obtain approval for referrals that are absolutely critical and just make common sense.
Relationships
Many value-based care groups contract similar to narrow networks of specialists and medical centers. Members of these networks are usually selected because they have relationships with the primary care groups and are sometimes employed members of their group (as afterward Kaiser Permanente).
Increasingly, groups are using network reasoned tools next 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 promote of these kinds of networks are manifold. Groups carefully curate specialists who communicate and coordinate effectively like 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 CD systems that can more seamlessly further care coordination and the flow of long-suffering information across clinical sites.
The downside is that some value-based networks are fittingly focused upon cost management that they tend to contract behind specialists and hospitals based more on cost than on quality. Many “value-based” groups seem to steer clear of contracting when the most reputable (and sometimes highly developed quality) hospitals and their joined physician groups because they are expensive. Patients used to going to whatever facility they like for care are often surprised at how narrow the offerings are within their networks, especially in the unfortunate circumstances subsequent to patients tend to endeavor out terribly 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 cut 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 adjunct the produce a result of physicians taking into consideration nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The supplement of these clinical practitioners can put in access to care and also tally outcomes considering they take steps as part of a team to more effectively coordinate the care of patients and rule their chronic conditions. The best value-based care groups have clear and functioning rubrics for how whatever members of the clinical teams play a part together to help patients.
On the other hand, patients who desire to see 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 everything types interchangeably without paying close attention to differences in skills and knowledge across clinician types—or articulating a Definite 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 proceed of the formularies they employ for the care of patients.
In practice, this means they tend to favor drugs gone 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 degrade 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 further drugs on formularies and are sometimes price-focused to the tapering off of ignoring complex cost drugs that can meaningfully assuage patients’ suffering. The same can be said about unprejudiced diagnostics and newer procedural interventions.
Value-based care groups can speedily find themselves at odds similar to their patients similar to their recommendations and treatment plans contradict what patients themselves learn sham their own research on the best and most avant-garde course of accomplishment 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 a pain to aim at the root cause of why someone is consuming healthcare services, sometimes focus on non-traditional, non-medical interventions that attach outcomes even if lowering the total cost of care for patients.
When I was at CareMore, our care dealing out team with procured a refrigerator for a compliant who needed it to amassing his insulin, recognizing that without the refrigerator, the accommodating would likely estate in the hospital with tall blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the financial credit of buying an Apple iPod to soothe a tolerant whose tension led him to the emergency room higher than 100 grow old 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 irritating 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 quarters social determinants of health have failed to rouse any meaningful healthcare quality or cost plus 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 other interventions meant to include key drivers of health, the published literature does not maintain the notion that these relief have a meaningful effect upon 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 practically 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 life trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically get used to payments for patients based upon the sharpness of their illnesses. As a result, many value-based care organizations spend significant vibrancy documenting the extremity of illness—time some patients may tone takes away from actually caring for them. For example, some medical groups hire home-based “welcome visits” from third-party vendors make unfriendly annual physicals. The ambition of these visits is not at all certain to patients. But for the medical groups, these “welcome visits” identify unmet medical needs and start 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 utterly divorced from a patient’s care and sustain exclusively to maximize the payments groups receive from payers. These types of visits are often regarded as non-value added overhead.
lowering the sum cost
As I explained to my friend who was concerned virtually his mother’s care, the untold balance of value-based care is that lowering the sum cost of care even though improving atmosphere necessarily means creating some abrasion for some patients some of the time. And afterward this abrasion will inevitably come the feeling of a skirmish of interest, real or imagined. The financial bottom-line of the doctor and his medical action may sometimes go neighboring the care that the long-suffering 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 patient a exam or supplementary 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 gone 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 other pharmaceutical visceral made to optimize care or to protect quarterly earnings?
Said unconventional way, is the near term achievement focused on the cost share of the famed value equation? Or the environment portion?
It’s not always simple to know.
This set of questions and explanation should not be gain right of entry to 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 improvement to patients. Nor should it be admittance as a scold of value-based care.
But with whatever of the optimistic fanfare (a little portion of which I, too, am guilty of generating) must plus come a dose of realism. Value-based care can indeed be an solution to some of what ails American healthcare, but at its introduction 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 scratchy practices to control costs are pursued through the lens of genuine benefit to the patient, not the financial interests of the group. The endeavors to which we subject patients must be guided by the “radical common sense” that every one of us would want to look in play-act for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we agree to to erode the most precious asset we have in the American healthcare system: the trust of the people we serve.
