Attend any healthcare conference and you’ll speedily discover that it’s become downright fashionable for healthcare leaders to talk about their unwavering commitment to “value-based care.”
The expression 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 school 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 management 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 once 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 simple enough—managing to a lower cost of care for a population of patients, while aiming to augment outcomes.
But what does this value-based care see like in practice in the real-world of long-suffering care (beyond the industry conference jargon and academic expositions upon the subject)?
I got the idea for this column after a recent call later than a near professor buddy 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 once her Medicare Advantage plan.
On one occasion, his mother was discharged from a hospital sooner than he felt she should have been (she was cutting edge readmitted). On marginal occasion, she was denied admission to a tertiary cancer center, where he believed she should have later than for a second opinion. And on 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 back up but think that he (and others) are anyhow failing to be stifling to the dots between the conformity of value-based care and its real-world implications. Which got me thinking that it perhaps might be cooperative for all 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 intend that partners contiguously with many value-based groups.
Tracking Hospital
While pharmaceutical costs get a lot of attention, the single most costly line item for many groups full of life in the “value-based care” space is presidency 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 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 admittance rates (admissions/1,000 patients) on a daily basis. The demean the numbers the better.
The overall intention is to try to avoid hospitalizations by contiguously managing patients in outpatient clinics and sometimes directly admitting patients to capable nursing facilities, whose costs are significantly demean than those of hospitals. Intensive outpatient presidency often includes enhanced right of entry to primary and urgent care and better paperwork of chronic disease—all in the same way as the ambition of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups plus make home calls to patients. The more technologically-enabled ones remotely monitor patients at particularly tall risk of hospitalization.
Such rough bed day management often translates into degrade hospitalization rates and shortened hospitalizations, but it can sometimes leave patients and families feeling quick and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be amazed when they’re discharged quickly to their homes with home care services or to skilled-nursing services in lieu of an additional 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 allowance because patients later end-stage conditions often gain admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes setting that their doctors are quickening them beside the passage of painkiller care and hospice prematurely, when they themselves have a desire to keep fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with anything of its joined tests and reasoned 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 gain in the hands of confident generalist primary care physicians who take more answerability for patients and their outcomes than those who undertaking in conventional primary care models. These generalist doctors only talk to to specialists subsequently they need an objector opinion or the uncomplaining requires a procedure that they aren’t practiced 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 dwell on and have poor outcomes appropriately of those delays. Because of the focus upon gatekeeping, patients often find themselves frustrated by utilization management—the administrative process through which health plans and medical groups review referrals to specialists and orders for investigative tests. And patients aren’t the deserted ones complaining. Almost all practicing doctor will say you stories very nearly how much exploit it sometimes takes to obtain commend for referrals that are absolutely indispensable and just make common sense.
Relationships
Many value-based care groups contract subsequent to narrow networks of specialists and medical centers. Members of these networks are usually prearranged because they have dealings with the primary care groups and are sometimes employed members of their group (as later Kaiser Permanente).
Increasingly, groups are using network critical tools later than Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and careful about their use of systematic tests and procedures.
The service of these kinds of networks are manifold. Groups carefully 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 on common electronic health record systems that can more seamlessly relief 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 supervision that they tend to contract later specialists and hospitals based more on cost than upon quality. Many “value-based” groups seem to steer sure of contracting in the same way as the most reputable (and sometimes future quality) hospitals and their united 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 subsequently patients tend to goal out intensely 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 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 feint of physicians bearing in mind nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The adjunct of these clinical practitioners can enhance access to care and also tally up outcomes as soon as they play-act as part of a team to more effectively coordinate the care of patients and run their chronic conditions. The best value-based care groups have distinct and functional rubrics for how whatever members of the clinical teams accomplish together to benefits patients.
On the new hand, patients who want to look physicians—or, sometimes, need to look 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 near 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 move on 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 degrade 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 other drugs on formularies and are sometimes price-focused to the narrowing of ignoring future cost drugs that can meaningfully put to rest patients’ suffering. The same can be said about ahead of its time diagnostics and newer procedural interventions.
Value-based care groups can speedily find themselves at odds taking into consideration their patients past their recommendations and treatment plans contradict what patients themselves learn show their own research on the best and most forward looking course of take action 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 aggravating to aim at the root cause of why someone is absorbing healthcare services, sometimes focus on non-traditional, non-medical interventions that swell outcomes even though lowering the total cost of care for patients.
When I was at CareMore, our care paperwork team once procured a refrigerator for a patient who needed it to store 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 story of buying an Apple iPod to soothe a uncomplaining whose protest led him to the emergency room greater than 100 epoch 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 maddening 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 futile to demonstrate any meaningful healthcare atmosphere or cost lead 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 additional interventions designed to count key drivers of health, the published literature does not retain the notion that these support have a meaningful effect on cost or the mood of outcomes—though the effect upon select individual patients is incontrovertible.
Revenue Focused?
While in its purest form, value-based healthcare is virtually 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 acclimatize payments for patients based upon the intensity of their illnesses. As a result, many value-based care organizations spend significant enthusiasm documenting the intensity of illness—time some patients may atmosphere takes away from actually caring for them. For example, some medical groups hire home-based “welcome visits” from third-party vendors set against annual physicals. The aspire of these visits is not at all positive 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 entirely divorced from a patient’s care and support exclusively to maximize the payments groups get from payers. These types of visits are often regarded as non-value further overhead.
lowering the total cost
As I explained to my buddy who was concerned about his mother’s care, the untold story of value-based care is that lowering the sum cost of care while improving feel necessarily means creating some abrasion for some patients some of the time. And in the same way as this abrasion will inevitably come the feeling of a clash of interest, real or imagined. The financial bottom-line of the doctor and his medical group 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 situation as a release lunch.”
When a doctor denies a tolerant a test or further drug or referral to a specialist, is it because we are in fact 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 further pharmaceutical creature made to optimize care or to protect quarterly earnings?
Said substitute way, is the near term play-act focused upon the cost allocation of the famed value equation? Or the tone portion?
It’s not always easy to know.
This set of questions and notes should not be door as a excuse 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 door as a chide of value-based care.
But with all of the optimistic fanfare (a small portion of which I, too, am guilty of generating) must afterward come a dose of realism. Value-based care can indeed be an answer 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 get 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 coarse practices to manage costs are pursued through the lens of authenticated 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 deed for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we allow to erode the most artificial asset we have in the American healthcare system: the trust of the people we serve.
