Attend any healthcare conference and you’ll speedily discover that it’s become downright in style for healthcare leaders to chat about their inflexible commitment to “value-based care.”
The a breath of roomy 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 instructor 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 bearing in mind 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 demean cost of care for a population of patients, while aiming to add up 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 similar to 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 action that was contracted subsequent to her Medicare Advantage plan.
On one occasion, his mommy was discharged from a hospital sooner than he felt she should have been (she was far along readmitted). On choice occasion, she was denied right of entry to a tertiary cancer center, where he believed she should have following for a second opinion. And on a third occasion, she was denied permission 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 put occurring to but think that he (and others) are somehow failing to link up the dots together with the covenant of value-based care and its real-world implications. Which got me thinking that it perhaps might be willing to help for everything of us to look closely at what value-based care means—good and bad—for patients receiving care governed by its principles.
These comments 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 aspire that partners contiguously with many value-based groups.
Tracking Hospital
While pharmaceutical costs get a lot of attention, the single most expensive line item for many groups functional in the “value-based care” space is supervision 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 infatuation of tracking hospital bed days (bed days/1,000 patients) and log on rates (admissions/1,000 patients) on a daily basis. The belittle the numbers the better.
The overall take aim is to try to avoid hospitalizations by next to managing patients in outpatient clinics and sometimes directly admitting patients to intelligent nursing facilities, whose costs are significantly demean than those of hospitals. Intensive outpatient dealing out often includes enhanced access to primary and urgent care and better management of chronic disease—all when the endeavor of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups after that make house calls to patients. The more technologically-enabled ones remotely monitor patients at particularly tall risk of hospitalization.
Such rough bed day giving out often translates into degrade hospitalization rates and abbreviated hospitalizations, but it can sometimes depart patients and families feeling brusque 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 facilities 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 event to do, and in share because patients once end-stage conditions often gain admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes character that their doctors are hastening them the length of the passage of numbing care and hospice prematurely, when they themselves have a desire to keep fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with all of its allied tests and methodical procedures—can be expensive. In fee-for-service environments, primary care physicians often direct 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 responsibility for patients and their outcomes than those who put-on in acknowledged primary care models. These generalist doctors only refer to specialists like they dependence an open-minded opinion or the patient requires a procedure that they aren’t able to con 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 poor outcomes suitably of those delays. Because of the focus upon gatekeeping, patients often locate themselves exasperated 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 on your own ones complaining. Almost all practicing doctor will say you stories virtually how much show it sometimes takes to obtain commendation for referrals that are absolutely vital and just make common sense.
Relationships
Many value-based care groups contract subsequently narrow networks of specialists and medical centers. Members of these networks are usually fixed because they have interaction with the primary care groups and are sometimes employed members of their group (as in the circulate of Kaiser Permanente).
Increasingly, groups are using network diagnostic tools in the aerate of 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 serve of these kinds of networks are manifold. Groups on purpose curate specialists who communicate and coordinate effectively behind 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 upon common electronic health CD systems that can more seamlessly encourage care coordination and the flow of patient information across clinical sites.
The downside is that some value-based networks are as a result focused upon cost doling out that they tend to contract later than specialists and hospitals based more upon cost than upon quality. Many “value-based” groups seem to steer positive of contracting subsequently the most reputable (and sometimes unconventional quality) hospitals and their associated physician groups because they are expensive. Patients used to going to all facility they with for care are often amazed at how narrow the offerings are within their networks, especially in the unfortunate circumstances bearing in mind patients tend to intention 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 condense 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 auxiliary the show of physicians taking into consideration nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The complement of these clinical practitioners can insert access to care and also augment outcomes subsequent to they produce a result as portion of a team to more effectively coordinate the care of patients and direct their chronic conditions. The best value-based care groups have positive and practicing rubrics for how all members of the clinical teams behave together to give bolster to patients.
On the additional hand, patients who desire to look physicians—or, sometimes, need to see physicians—often gain frustrated that access 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 near attention to differences in skills and knowledge across clinician types—or articulating a sure 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 loan of the formularies they employ for the care of patients.
In practice, this means they tend to favor drugs bearing in mind 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 belittle 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 further drugs upon formularies and are sometimes price-focused to the narrowing of ignoring higher cost drugs that can meaningfully relieve patients’ suffering. The same can be said about unbiased diagnostics and newer procedural interventions.
Value-based care groups can speedily find themselves at odds past their patients next their recommendations and treatment plans contradict what patients themselves learn do its stuff their own research upon the best and most innovative course of statute for their condition.
Pro Non-Medical Interventions
Many groups that are “value-based” assume full responsibility (often known as “full risk”) for the total cost of care. These groups, which are known for grating to goal at the root cause of why someone is consuming healthcare services, sometimes focus on non-traditional, non-medical interventions that tote up outcomes while lowering the total cost of care for patients.
When I was at CareMore, our care running team later than procured a refrigerator for a uncomplaining who needed it to addition his insulin, recognizing that without the refrigerator, the compliant would likely house in the hospital with tall blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the bank account of buying an Apple iPod to soothe a compliant whose demonstration led him to the emergency room greater than 100 time 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 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 domicile social determinants of health have fruitless to disturb any meaningful healthcare vibes 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 further interventions designed to include key drivers of health, the published literature does not maintain the notion that these give support to have a meaningful effect upon cost or the tone of outcomes—though the effect upon select individual patients is incontrovertible.
Revenue Focused?
While in its purest form, value-based healthcare is just about 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 accustom yourself payments for patients based upon the intensity of their illnesses. As a result, many value-based care organizations spend significant cartoon documenting the height of illness—time some patients may character takes away from actually caring for them. For example, some medical groups employ home-based “welcome visits” from third-party vendors distance annual physicals. The point of these visits is not at all clear 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 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 added overhead.
lowering the total cost
As I explained to my buddy who was concerned not quite his mother’s care, the untold savings account of value-based care is that lowering the total cost of care though improving character 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 court case of interest, real or imagined. The financial bottom-line of the doctor and his medical action 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 concern as a pardon lunch.”
When a doctor denies a long-suffering a exam or additional drug or referral to a specialist, is it because we are truly optimizing the care of the patient?
Or is it because we are optimizing the economics of the value-based group?
In an era considering 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 subconscious made to optimize care or to guard quarterly earnings?
Said complementary way, is the near term put on an act focused on the cost portion of the famed value equation? Or the air portion?
It’s not always easy to know.
This set of questions and explanation should not be approach as a defense of the costly, traditional fee-for-service system, which has its own skew towards over-delivering care, often with Tiny to no lead to patients. Nor should it be gate as a caution of value-based care.
But with everything of the optimistic fanfare (a little portion of which I, too, am guilty of generating) must also come a dose of realism. Value-based care can indeed be an answer to some of what ails American healthcare, but at its foundation there must be something somewhat increasingly quaint and elusive:
An ethical underpinning to always realize 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 rough practices to control costs are pursued through the lens of valid 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 every one of us would want to look in doing for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we take on to erode the most precious asset we have in the American healthcare system: the trust of the people we serve.
