Attend any healthcare conference and you’ll speedily discover that it’s become downright fashionable for healthcare leaders to talk about their steadfast commitment to “value-based care.”
The discussion 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 moot 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 meting 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 as soon as 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 append outcomes.
But what does this value-based care see like in practice in the real-world of accommodating care (beyond the industry conference jargon and academic expositions upon the subject)?
I got the idea for this column after a recent call similar to a near professor friend who has long been a aficionado of value-based care. On our call, he expressed dismay at his mother’s care in a value-based medical group that was contracted behind her Medicare Advantage plan.
On one occasion, his mommy was discharged from a hospital sooner than he felt she should have been (she was well ahead readmitted). On complementary occasion, she was denied admission to a tertiary cancer center, where he believed she should have bearing in mind for a second opinion. And on a third occasion, she was denied admission 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 but think that he (and others) are anyhow failing to connect the dots together with the bargain of value-based care and its real-world implications. Which got me thinking that it perhaps might be long-suffering for all of us to look closely at what value-based care means—good and bad—for patients receiving care governed by its principles.
These observations 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 wish that partners alongside with many value-based groups.
Tracking Hospital
While pharmaceutical costs gain a lot of attention, the single most expensive line item for many groups effective in the “value-based care” space is government of acute hospital bed days. A morning 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 entry rates (admissions/1,000 patients) on a daily basis. The demean the numbers the better.
The overall point toward is to attempt to avoid hospitalizations by to the side of managing patients in outpatient clinics and sometimes directly admitting patients to adept nursing facilities, whose costs are significantly demean than those of hospitals. Intensive outpatient organization often includes enhanced entrance to primary and urgent care and better running of chronic disease—all later than the intention of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups after that make home calls to patients. The more technologically-enabled ones remotely monitor patients at particularly high risk of hospitalization.
Such rasping bed day dealing out often translates into subjugate hospitalization rates and condensed hospitalizations, but it can sometimes depart patients and families feeling short and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be surprised when they’re discharged rudely to their homes with house care services or to skilled-nursing facilities in lieu of an further few nights in the hospital.
In addition, many value-based care groups prioritize painkilling care and proactively transition patients to hospice—in part, because it’s often the right situation to do, and in part because patients when end-stage conditions often get admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes atmosphere that their doctors are quickening them the length of the passage of painkilling 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 associated tests and systematic procedures—can be expensive. In fee-for-service environments, primary care physicians often lecture 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 help in the hands of confident generalist primary care physicians who take more liability for patients and their outcomes than those who be in in normal primary care models. These generalist doctors only tackle to specialists next they need an innovative opinion or the long-suffering requires a procedure that they aren’t dexterous to decree 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 poor outcomes thus of those delays. Because of the focus on gatekeeping, patients often locate themselves annoyed 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 unaided ones complaining. Almost all practicing doctor will tell you stories just about how much perform it sometimes takes to obtain applause for referrals that are absolutely necessary and just make common sense.
Relationships
Many value-based care groups contract in the same way as 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 like Kaiser Permanente).
Increasingly, groups are using network investigative tools in imitation of Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and careful about their use of logical tests and procedures.
The promote of these kinds of networks are manifold. Groups with intent curate specialists who communicate and coordinate effectively when 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 scrap book systems that can more seamlessly assist care coordination and the flow of tolerant information across clinical sites.
The downside is that some value-based networks are suitably focused upon cost government that they tend to contract like specialists and hospitals based more on cost than upon quality. Many “value-based” groups seem to steer clear of contracting taking into consideration the most reputable (and sometimes cutting edge quality) hospitals and their allied physician groups because they are expensive. Patients used to going to everything facility they behind for care are often surprised at how narrow the offerings are within their networks, especially in the unfortunate circumstances once patients tend to take aim out severely 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 cut costs, many value-based care groups often introduce new 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 con of physicians next nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The addition of these clinical practitioners can include access to care and also total outcomes subsequent to they operate as ration 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 committed rubrics for how everything members of the clinical teams act out together to benefits patients.
On the new hand, patients who desire to see physicians—or, sometimes, need to look 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 anything types interchangeably without paying near 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 spread of the formularies they hire for the care of patients.
In practice, this means they tend to favor drugs like 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 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 extra drugs upon formularies and are sometimes price-focused to the point of ignoring sophisticated cost drugs that can meaningfully assuage patients’ suffering. The thesame can be said about objector diagnostics and newer procedural interventions.
Value-based care groups can quickly find themselves at odds taking into account their patients similar to their recommendations and treatment plans contradict what patients themselves learn do something their own research on the best and most highly developed course of produce a result 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 infuriating to determination at the root cause of why someone is absorbing healthcare services, sometimes focus on non-traditional, non-medical interventions that put in outcomes even though lowering the total cost of care for patients.
When I was at CareMore, our care supervision team behind procured a refrigerator for a accommodating who needed it to increase his insulin, recognizing that without the refrigerator, the patient would likely land in the hospital with tall blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the savings account of buying an Apple iPod to soothe a long-suffering whose distress led him to the emergency room higher than 100 era 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 bothersome to access 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 unsuccessful to rouse any meaningful healthcare mood or cost pro to the programs.
What’s more, while many value-based care organizations (including two I have led) provide entrance to gym benefits, transportation, food, and extra interventions intended to affix key drivers of health, the published literature does not maintain the notion that these sustain have a meaningful effect on cost or the setting 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 sum cost of care by ensuring that patients are healthier and are making judicious use of the healthcare system, many organizations spend significant excitement trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically adapt payments for patients based upon the intensity of their illnesses. As a result, many value-based care organizations spend significant activity documenting the sharpness 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 separate from annual physicals. The try of these visits is not at all sure 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 unquestionably divorced from a patient’s care and foster 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 just about his mother’s care, the untold relation of value-based care is that lowering the sum cost of care even though improving environment necessarily means creating some abrasion for some patients some of the time. And similar to this abrasion will inevitably come the feeling of a achievement of interest, real or imagined. The financial bottom-line of the doctor and his medical work may sometimes go next to 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 forgive lunch.”
When a doctor denies a patient a test or supplementary drug or referral to a specialist, is it because we are essentially optimizing the care of the patient?
Or is it because we are optimizing the economics of the value-based group?
In an era taking into consideration 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 brute made to optimize care or to protect quarterly earnings?
Said complementary way, is the close term be active focused upon the cost allocation of the famed value equation? Or the tone portion?
It’s not always simple to know.
This set of questions and clarification should not be open as a reason of the costly, traditional fee-for-service system, which has its own skew towards over-delivering care, often with little to no lead to patients. Nor should it be way in as a warn about of value-based care.
But with all of the optimistic fanfare (a small portion of which I, too, am guilty of generating) must plus come a dose of realism. Value-based care can indeed be an answer to some of what ails American healthcare, but at its instigation 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 severe practices to manage costs are pursued through the lens of valid benefit to the patient, not the financial interests of the group. The activities to which we subject patients must be guided by the “radical common sense” that every one of us would desire to look in behave for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we agree to to erode the most artificial asset we have in the American healthcare system: the trust of the people we serve.
