Attend any healthcare conference and you’ll speedily discover that it’s become downright all the rage for healthcare leaders to chat about their resolute 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 intellectual 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 paperwork 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 later than 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 demean cost of care for a population of patients, while aiming to intensify outcomes.
But what does this value-based care look like in practice in the real-world of accommodating care (beyond the industry conference jargon and academic expositions on the subject)?
I got the idea for this column after a recent call later than a close professor friend who has long been a fan of value-based care. On our call, he expressed dismay at his mother’s care in a value-based medical work that was contracted afterward her Medicare Advantage plan.
On one occasion, his mother was discharged from a hospital sooner than he felt she should have been (she was well along readmitted). On other occasion, she was denied right of entry to a tertiary cancer center, where he believed she should have gone for a second opinion. And upon a third occasion, she was denied permission to a specialist who my friend felt could have corrected an earlier, botched cataract surgery.
As my friend decried his mother’s care experience, I couldn’t help but think that he (and others) are somehow failing to border the dots amid the promise of value-based care and its real-world implications. Which got me thinking that it perhaps might be accepting 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 explanation arise from my get older 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 take aim that partners closely with many value-based groups.
Tracking Hospital
While pharmaceutical costs get a lot of attention, the single most expensive line item for many groups operational in the “value-based care” space is paperwork 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 hours of 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 admittance rates (admissions/1,000 patients) on a daily basis. The lower the numbers the better.
The overall strive for is to attempt to avoid hospitalizations by nearby 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 handing out often includes enhanced access to primary and urgent care and better supervision of chronic disease—all once the plan of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups furthermore make home calls to patients. The more technologically-enabled ones remotely monitor patients at particularly tall risk of hospitalization.
Such severe bed day running often translates into demean hospitalization rates and reduced hospitalizations, but it can sometimes leave patients and families feeling unexpected and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be surprised when they’re discharged tersely to their homes with home care facilities or to skilled-nursing facilities in lieu of an other few nights in the hospital.
In addition, many value-based care groups prioritize palliative care and proactively transition patients to hospice—in part, because it’s often the right matter to do, and in share because patients taking into consideration 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 hastening them beside the lane of pain-relieving care and hospice prematurely, when they themselves have a want to save fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with anything of its allied tests and investigative 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 improvement in the hands of confident generalist primary care physicians who accept more answerability for patients and their outcomes than those who law in time-honored primary care models. These generalist doctors only talk to to specialists as soon as they dependence an modern opinion or the compliant requires a procedure that they aren’t competent to exploit 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 hence of those delays. Because of the focus on gatekeeping, patients often locate themselves incensed by utilization management—the administrative process through which health plans and medical groups review referrals to specialists and orders for logical tests. And patients aren’t the unaided ones complaining. Almost all practicing doctor will tell you stories practically how much produce an effect it sometimes takes to obtain praise for referrals that are absolutely vital and just make common sense.
Relationships
Many value-based care groups contract when narrow networks of specialists and medical centers. Members of these networks are usually prearranged because they have contact with the primary care groups and are sometimes employed members of their group (as bearing in mind Kaiser Permanente).
Increasingly, groups are using network methodical tools similar to 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 minister to of these kinds of networks are manifold. Groups purposefully curate specialists who communicate and coordinate effectively with 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 folder systems that can more seamlessly abet care coordination and the flow of tolerant information across clinical sites.
The downside is that some value-based networks are fittingly focused on cost executive that they tend to contract subsequent to specialists and hospitals based more upon cost than on quality. Many “value-based” groups seem to steer clear of contracting considering the most reputable (and sometimes progressive 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 similar to patients tend to goal out highly 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 shorten 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 summit of the license.” In practice, it means groups complement the be in of physicians taking into consideration nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The accessory of these clinical practitioners can include access to care and also total outcomes in the atmosphere of they action as ration 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 involved rubrics for how all members of the clinical teams play a part together to facilitate patients.
On the other hand, patients who want to look physicians—or, sometimes, need to see physicians—often get 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 certain 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 increase 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 subjugate 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 additional drugs on formularies and are sometimes price-focused to the point of ignoring progressive cost drugs that can meaningfully alleviate patients’ suffering. The same can be said about innovative diagnostics and newer procedural interventions.
Value-based care groups can speedily find themselves at odds in imitation of their patients following their recommendations and treatment plans contradict what patients themselves learn perform their own research upon the best and most liberal 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 maddening to objective at the root cause of why someone is consuming healthcare services, sometimes focus on non-traditional, non-medical interventions that total outcomes while lowering the total cost of care for patients.
When I was at CareMore, our care management team gone procured a refrigerator for a tolerant who needed it to growth his insulin, recognizing that without the refrigerator, the patient would likely estate in the hospital with high blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the report of buying an Apple iPod to soothe a patient whose confrontation led him to the emergency room beyond 100 times 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 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 habitat social determinants of health have failed to move around any meaningful healthcare feel or cost gain 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 supplementary interventions meant to intensify key drivers of health, the published literature does not hold the notion that these foster have a meaningful effect on cost or the vibes of outcomes—though the effect on select individual patients is incontrovertible.
Revenue Focused?
While in its purest form, value-based healthcare is virtually 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 energy trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically get used to payments for patients based on the height of their illnesses. As a result, many value-based care organizations spend significant liveliness documenting the sharpness of illness—time some patients may quality takes away from actually caring for them. For example, some medical groups hire home-based “welcome visits” from third-party vendors turn away from annual physicals. The target of these visits is not at all positive to patients. But for the medical groups, these “welcome visits” identify unmet medical needs and activate 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 unconditionally divorced from a patient’s care and service exclusively to maximize the payments groups receive 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 roughly his mother’s care, the untold report of value-based care is that lowering the total cost of care while improving mood necessarily means creating some abrasion for some patients some of the time. And taking into account this abrasion will inevitably come the feeling of a encounter of interest, real or imagined. The financial bottom-line of the doctor and his medical help may sometimes go adjoining 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 long-suffering a test 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 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 beast made to optimize care or to protect quarterly earnings?
Said another way, is the close term pretense focused upon the cost allowance of the famed value equation? Or the setting portion?
It’s not always simple to know.
This set of questions and explanation should not be right to use 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 retrieve as a reprimand of value-based care.
But with whatever of the optimistic fanfare (a small portion of which I, too, am guilty of generating) must moreover come a dose of realism. Value-based care can indeed be an solution to some of what ails American healthcare, but at its opening there must be something somewhat increasingly quaint and elusive:
An ethical underpinning to always complete 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 legal benefit to the patient, not the financial interests of the group. The actions to which we subject patients must be guided by the “radical common sense” that every one of us would desire to look in sham for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we give a approving response to erode the most unnatural asset we have in the American healthcare system: the trust of the people we serve.
