Attend any healthcare conference and you’ll speedily discover that it’s become downright well-liked for healthcare leaders to chat about their unbending commitment to “value-based care.”
The exposure 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 literary 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 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 subjugate cost of care for a population of patients, while aiming to include 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 on the subject)?
I got the idea for this column after a recent call following 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 intervention that was contracted bearing in mind her Medicare Advantage plan.
On one occasion, his mom was discharged from a hospital sooner than he felt she should have been (she was far along readmitted). On out of the ordinary occasion, she was denied entrance to a tertiary cancer center, where he believed she should have taking into account for a second opinion. And upon a third occasion, she was denied right of entry 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 help but think that he (and others) are someway failing to link up the dots in the midst of the covenant of value-based care and its real-world implications. Which got me thinking that it perhaps might be willing to help for anything of us to see closely at what value-based care means—good and bad—for patients receiving care governed by its principles.
These observations arise from my time 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 objective that partners contiguously with many value-based groups.
Tracking Hospital
While pharmaceutical costs gain a lot of attention, the single most costly line item for many groups in action in the “value-based care” space is executive 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 craving of tracking hospital bed days (bed days/1,000 patients) and contact rates (admissions/1,000 patients) on a daily basis. The demean the numbers the better.
The overall target is to attempt to avoid hospitalizations by nearby managing patients in outpatient clinics and sometimes directly admitting patients to gifted nursing facilities, whose costs are significantly belittle than those of hospitals. Intensive outpatient giving out often includes enhanced permission to primary and urgent care and better supervision of chronic disease—all like the direct of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups with make home calls to patients. The more technologically-enabled ones remotely monitor patients at particularly tall risk of hospitalization.
Such prickly bed day paperwork often translates into degrade 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 quickly to their homes with house care facilities or to skilled-nursing facilities in lieu of an new 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 following end-stage conditions often gain admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes environment that their doctors are increase of velocity them all along the passageway of pain-relieving care and hospice prematurely, when they themselves have a desire to save fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with all of its united tests and analytical procedures—can be expensive. In fee-for-service environments, primary care physicians often attend 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 gain in the hands of confident generalist primary care physicians who take more responsibility for patients and their outcomes than those who proceed in normal primary care models. These generalist doctors only take in hand to specialists considering they need an open-minded opinion or the compliant requires a procedure that they aren’t skilled to play in 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 in view of that of those delays. Because of the focus on gatekeeping, patients often find 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 lonely ones complaining. Almost every practicing doctor will say you stories about how much perform it sometimes takes to obtain cheer for referrals that are absolutely vital and just make common sense.
Relationships
Many value-based care groups contract following narrow networks of specialists and medical centers. Members of these networks are usually chosen because they have contact with the primary care groups and are sometimes employed members of their group (as considering Kaiser Permanente).
Increasingly, groups are using network reasoned tools next Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and cautious about their use of diagnostic tests and procedures.
The assistance of these kinds of networks are manifold. Groups intentionally curate specialists who communicate and coordinate effectively in the proclaim 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 see for….?”). And these specialists often operate upon common electronic health compilation systems that can more seamlessly support care coordination and the flow of compliant information across clinical sites.
The downside is that some value-based networks are therefore focused on cost management that they tend to contract with specialists and hospitals based more upon cost than upon quality. Many “value-based” groups seem to steer Definite of contracting in imitation of the most reputable (and sometimes innovative quality) hospitals and their associated physician groups because they are expensive. Patients used to going to anything facility they later for care are often amazed at how narrow the offerings are within their networks, especially in the unfortunate circumstances when patients tend to strive for 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 shorten 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 top of the license.” In practice, it means groups supplement the doing of physicians past nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The complement of these clinical practitioners can improve access to care and also affix outcomes subsequent to they enactment as allowance of a team to more effectively coordinate the care of patients and rule their chronic conditions. The best value-based care groups have Definite and involved rubrics for how whatever members of the clinical teams function together to facilitate patients.
On the other hand, patients who want to look physicians—or, sometimes, need to see physicians—often gain frustrated that 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 all types interchangeably without paying near attention to differences in skills and knowledge across clinician types—or articulating a distinct 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 employ for the care of patients.
In practice, this means they tend to favor drugs in the proclaim of 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 cutting edge cost drugs that can meaningfully calm patients’ suffering. The same can be said about radical diagnostics and newer procedural interventions.
Value-based care groups can quickly find themselves at odds subsequently their patients bearing in mind their recommendations and treatment plans contradict what patients themselves learn play their own research on the best and most enlightened 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 total cost of care. These groups, which are known for bothersome to aim at the root cause of why someone is absorbing healthcare services, sometimes focus upon non-traditional, non-medical interventions that tote up outcomes though lowering the sum cost of care for patients.
When I was at CareMore, our care meting out team past procured a refrigerator for a patient who needed it to amassing 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 tally of buying an Apple iPod to soothe a long-suffering whose campaigning led him to the emergency room exceeding 100 get older 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 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 habitat social determinants of health have futile to stir in the air opinion any meaningful healthcare mood or cost lead 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 meant to tally up key drivers of health, the published literature does not support the notion that these encouragement have a meaningful effect upon cost or the mood of outcomes—though the effect on select individual patients is incontrovertible.
Revenue Focused?
While in its purest form, value-based healthcare is roughly 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 familiarize payments for patients based on the sharpness of their illnesses. As a result, many value-based care organizations spend significant energy documenting the intensity of illness—time some patients may environment takes away from actually caring for them. For example, some medical groups employ home-based “welcome visits” from third-party vendors push away annual physicals. The intend of these visits is not at all Definite to patients. But for the medical groups, these “welcome visits” identify unmet medical needs and set in motion 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 no question divorced from a patient’s care and help exclusively to maximize the payments groups get from payers. These types of visits are often regarded as non-value other overhead.
lowering the total cost
As I explained to my friend who was concerned practically his mother’s care, the untold credit of value-based care is that lowering the total cost of care though improving air necessarily means creating some abrasion for some patients some of the time. And following this abrasion will inevitably come the feeling of a suit of interest, real or imagined. The financial bottom-line of the doctor and his medical intervention may sometimes go next to the care that the uncomplaining feels he or she needs. As my late economics teacher, Martin S. Feldstein, often said, “There’s no such concern as a clear lunch.”
When a doctor denies a accommodating a exam or supplementary 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 later 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 other way, is the near term behave focused on the cost allocation of the famed value equation? Or the air portion?
It’s not always simple to know.
This set of questions and clarification should not be approach 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 help to patients. Nor should it be gate as a chide of value-based care.
But with everything of the optimistic fanfare (a little portion of which I, too, am guilty of generating) must in addition to come a dose of realism. Value-based care can indeed be an solution to some of what ails American healthcare, but at its inauguration there must be something somewhat increasingly quaint and elusive:
An ethical underpinning to always accomplish 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 rude practices to manage costs are pursued through the lens of legal 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 all one of us would want to look in perform for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we tolerate to erode the most unnatural asset we have in the American healthcare system: the trust of the people we serve.
