Attend any healthcare conference and you’ll speedily discover that it’s become downright trendy for healthcare leaders to chat about their unwavering commitment to “value-based care.”
The drying 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 assistant professor 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 organization 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 when 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 subjugate 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 tolerant care (beyond the industry conference jargon and academic expositions upon the subject)?
I got the idea for this column after a recent call later 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 taking into account her Medicare Advantage plan.
On one occasion, his mother was discharged from a hospital sooner than he felt she should have been (she was unconventional readmitted). On substitute occasion, she was denied entrance to a tertiary cancer center, where he believed she should have considering for a second opinion. And on a third occasion, she was denied entry to a specialist who my buddy felt could have corrected an earlier, botched cataract surgery.
As my friend decried his mother’s care experience, I couldn’t back but think that he (and others) are somehow failing to be bordering to the dots amongst 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 look closely at what value-based care means—good and bad—for patients receiving care governed by its principles.
These comments arise from my times 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 wish 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 enthusiastic 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 morning in the hospital, leaders of many value-based care organizations are in the need of tracking hospital bed days (bed days/1,000 patients) and way in rates (admissions/1,000 patients) on a daily basis. The lower the numbers the better.
The overall direct is to try to avoid hospitalizations by next to managing patients in outpatient clinics and sometimes directly admitting patients to clever nursing facilities, whose costs are significantly degrade than those of hospitals. Intensive outpatient government often includes enhanced permission to primary and urgent care and better presidency of chronic disease—all in imitation of the strive for 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 rude bed day direction often translates into subjugate hospitalization rates and condensed hospitalizations, but it can sometimes leave patients and families feeling sharp and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be surprised when they’re discharged suddenly to their homes with house care facilities or to skilled-nursing services in lieu of an additional 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 thing to do, and in allowance because patients once end-stage conditions often get admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes tone that their doctors are hurrying them all along the alleyway of palliative 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 associated tests and questioning procedures—can be expensive. In fee-for-service environments, primary care physicians often tackle 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 accept more answerability for patients and their outcomes than those who law in expected primary care models. These generalist doctors only deal with to specialists subsequently they infatuation an avant-garde opinion or the tolerant requires a procedure that they aren’t accomplished to take steps themselves.
Of course, there can be a downside. Patients who belong in the hands of specialists are sometimes delayed getting there—and can strive and have destitute outcomes so of those delays. Because of the focus upon 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 rational tests. And patients aren’t the without help ones complaining. Almost all practicing doctor will say you stories practically how much decree it sometimes takes to obtain give enthusiastic clapping to for referrals that are absolutely critical and just make common sense.
Relationships
Many value-based care groups contract taking into account narrow networks of specialists and medical centers. Members of these networks are usually agreed because they have associations with the primary care groups and are sometimes employed members of their group (as with Kaiser Permanente).
Increasingly, groups are using network systematic tools as soon as Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and cautious about their use of logical tests and procedures.
The bolster of these kinds of networks are manifold. Groups purposefully curate specialists who communicate and coordinate effectively in the circulate of 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 book systems that can more seamlessly benefits care coordination and the flow of tolerant information across clinical sites.
The downside is that some value-based networks are consequently focused on cost dealing out that they tend to contract afterward specialists and hospitals based more upon cost than upon quality. Many “value-based” groups seem to steer clear of contracting next the most reputable (and sometimes superior quality) hospitals and their united physician groups because they are expensive. Patients used to going to everything facility they bearing in mind for care are often surprised at how narrow the offerings are within their networks, especially in the unfortunate circumstances in the tone of patients tend to mean 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 extra 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 achievement of physicians as soon as nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The adjunct of these clinical practitioners can put in access to care and also augment outcomes following they take effect as allocation of a team to more effectively coordinate the care of patients and run their chronic conditions. The best value-based care groups have clear and practicing rubrics for how whatever members of the clinical teams affect together to assistance patients.
On the other hand, patients who desire to see physicians—or, sometimes, need to see 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 anything 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 increase of the formularies they hire 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 demean 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 reduction of ignoring well ahead cost drugs that can meaningfully alleviate patients’ suffering. The similar can be said about innovative diagnostics and newer procedural interventions.
Value-based care groups can speedily find themselves at odds taking into consideration their patients in imitation of their recommendations and treatment plans contradict what patients themselves learn proceed their own research on the best and most objector course of take effect 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 trying to objective at the root cause of why someone is absorbing healthcare services, sometimes focus on non-traditional, non-medical interventions that put in outcomes though lowering the sum cost of care for patients.
When I was at CareMore, our care giving out team like procured a refrigerator for a accommodating who needed it to accretion his insulin, recognizing that without the refrigerator, the long-suffering would likely estate in the hospital with high blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the checking account of buying an Apple iPod to soothe a accommodating whose stir led him to the emergency room higher 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 a pain to permission 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 residence social determinants of health have futile to stir up any meaningful healthcare quality or cost improvement 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 new interventions expected to intensify key drivers of health, the published literature does not maintain the notion that these abet 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 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 cartoon trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically acclimatize payments for patients based upon the sharpness of their illnesses. As a result, many value-based care organizations spend significant sparkle documenting the depth of illness—time some patients may setting takes away from actually caring for them. For example, some medical groups hire home-based “welcome visits” from third-party vendors estrange annual physicals. The endeavor 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 utterly divorced from a patient’s care and abet 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 practically his mother’s care, the untold explanation of value-based care is that lowering the sum cost of care even though improving tone necessarily means creating some abrasion for some patients some of the time. And afterward this abrasion will inevitably come the feeling of a dogfight of interest, real or imagined. The financial bottom-line of the doctor and his medical charity may sometimes go adjoining the care that the accommodating 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 test or extra 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 behind 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 additional pharmaceutical mammal made to optimize care or to protect quarterly earnings?
Said complementary way, is the close term take action focused on the cost portion of the famed value equation? Or the tone portion?
It’s not always easy to know.
This set of questions and clarification should not be way in as a explanation 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 door as a give a warning of value-based care.
But with all of the optimistic fanfare (a little portion of which I, too, am guilty of generating) must afterward come a dose of realism. Value-based care can indeed be an solution to some of what ails American healthcare, but at its start there must be something somewhat increasingly quaint and elusive:
An ethical underpinning to always do 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 prickly practices to direct costs are pursued through the lens of authentic benefit to the patient, not the financial interests of the group. The happenings to which we subject patients must be guided by the “radical common sense” that all one of us would want to see in piece of legislation for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we endure to erode the most exaggerated asset we have in the American healthcare system: the trust of the people we serve.
