Attend any healthcare conference and you’ll speedily discover that it’s become downright well-liked for healthcare leaders to chat about their immovable commitment to “value-based care.”
The exposure to 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 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 direction 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 similar to 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 belittle cost of care for a population of patients, while aiming to count 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 upon the subject)?
I got the idea for this column after a recent call in the same way as a close 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 action that was contracted as soon as her Medicare Advantage plan.
On one occasion, his mother was discharged from a hospital sooner than he felt she should have been (she was higher readmitted). On complementary occasion, she was denied access to a tertiary cancer center, where he believed she should have in the same way as for a second opinion. And upon a third occasion, she was denied access 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 assist but think that he (and others) are anyhow failing to border the dots with the promise of value-based care and its real-world implications. Which got me thinking that it perhaps might be cooperative 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 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 endeavor that partners contiguously with many value-based groups.
Tracking Hospital
While pharmaceutical costs get a lot of attention, the single most costly line item for many groups enthusiastic in the “value-based care” space is giving out of acute hospital bed days. A daylight 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 craving of tracking hospital bed days (bed days/1,000 patients) and entrйe rates (admissions/1,000 patients) on a daily basis. The demean the numbers the better.
The overall intend is to try to avoid hospitalizations by contiguously managing patients in outpatient clinics and sometimes directly admitting patients to talented nursing facilities, whose costs are significantly lower than those of hospitals. Intensive outpatient management often includes enhanced entry to primary and urgent care and better handing out of chronic disease—all behind the seek of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups furthermore make house calls to patients. The more technologically-enabled ones remotely monitor patients at particularly high risk of hospitalization.
Such gruff bed day government often translates into belittle hospitalization rates and reduced hospitalizations, but it can sometimes leave patients and families feeling hasty and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be surprised when they’re discharged gruffly to their homes with home care services or to skilled-nursing facilities 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 business to do, and in part because patients when end-stage conditions often gain admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes vibes that their doctors are increase in speed them down the lane of pain-relieving 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 joined tests and questioning 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 lead in the hands of confident generalist primary care physicians who accept more answerability for patients and their outcomes than those who pretense in traditional primary care models. These generalist doctors only deal with to specialists in the expose of they compulsion an ahead of its time opinion or the compliant requires a procedure that they aren’t dexterous to do something 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 as a result of those delays. Because of the focus on gatekeeping, patients often find themselves enraged by utilization management—the administrative process through which health plans and medical groups review referrals to specialists and orders for systematic tests. And patients aren’t the by yourself ones complaining. Almost all practicing doctor will tell you stories not quite how much deed it sometimes takes to obtain approbation for referrals that are absolutely valuable 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 selected because they have contact with the primary care groups and are sometimes employed members of their group (as like Kaiser Permanente).
Increasingly, groups are using network critical tools taking into consideration Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and cautious about their use of reasoned tests and procedures.
The bolster of these kinds of networks are manifold. Groups intentionally curate specialists who communicate and coordinate effectively considering 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 wedding album systems that can more seamlessly serve care coordination and the flow of long-suffering information across clinical sites.
The downside is that some value-based networks are hence focused upon cost dispensation that they tend to contract bearing in mind 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 future quality) hospitals and their associated physician groups because they are expensive. Patients used to going to everything facility they following for care are often amazed at how narrow the offerings are within their networks, especially in the unfortunate circumstances following patients tend to try out very 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 auxiliary the play of physicians considering nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The addition of these clinical practitioners can adjoin access to care and also count up outcomes considering they take action as allocation 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 everything members of the clinical teams put it on together to relief patients.
On the extra hand, patients who want to look physicians—or, sometimes, need to look physicians—often gain frustrated that admission 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 positive 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 move forward of the formularies they employ for the care of patients.
In practice, this means they tend to favor drugs next 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 lessening of ignoring sophisticated cost drugs that can meaningfully calm patients’ suffering. The similar can be said about enlightened diagnostics and newer procedural interventions.
Value-based care groups can quickly find themselves at odds bearing in mind their patients similar to their recommendations and treatment plans contradict what patients themselves learn appear in their own research upon the best and most radical course of deed 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 irritating to aspiration at the root cause of why someone is absorbing healthcare services, sometimes focus on non-traditional, non-medical interventions that increase outcomes while lowering the total cost of care for patients.
When I was at CareMore, our care admin team later than procured a refrigerator for a uncomplaining who needed it to hoard his insulin, recognizing that without the refrigerator, the accommodating would likely home in the hospital with tall blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the tally of buying an Apple iPod to soothe a tolerant whose anxiety led him to the emergency room beyond 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 bothersome 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 futile to stir any meaningful healthcare air or cost pro to the programs.
What’s more, while many value-based care organizations (including two I have led) provide access to gym benefits, transportation, food, and additional interventions intended to intensify key drivers of health, the published literature does not sustain the notion that these sustain 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 approximately 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 animatronics trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically adjust payments for patients based on the sharpness of their illnesses. As a result, many value-based care organizations spend significant liveliness documenting the extremity of illness—time some patients may environment 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 mean of these visits is not at all positive to patients. But for the medical groups, these “welcome visits” identify unmet medical needs and put into action 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 agreed divorced from a patient’s care and encouragement exclusively to maximize the payments groups get from payers. These types of visits are often regarded as non-value supplementary overhead.
lowering the total cost
As I explained to my friend who was concerned virtually his mother’s care, the untold report of value-based care is that lowering the total cost of care even though improving environment necessarily means creating some abrasion for some patients some of the time. And following this abrasion will inevitably come the feeling of a charge of interest, real or imagined. The financial bottom-line of the doctor and his medical bureau may sometimes go against the care that the uncomplaining feels he or she needs. As my late economics teacher, Martin S. Feldstein, often said, “There’s no such business as a release lunch.”
When a doctor denies a uncomplaining a exam or new drug or referral to a specialist, is it because we are in fact optimizing the care of the patient?
Or is it because we are optimizing the economics of the value-based group?
In an era with 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 visceral made to optimize care or to guard quarterly earnings?
Said unorthodox way, is the near term accomplishment focused upon the cost allocation of the famed value equation? Or the atmosphere portion?
It’s not always simple to know.
This set of questions and interpretation should not be entry as a excuse 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 admission as a scold of value-based care.
But with everything of the optimistic fanfare (a small portion of which I, too, am guilty of generating) must along with come a dose of realism. Value-based care can indeed be an solution to some of what ails American healthcare, but at its launch 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 gruff practices to manage costs are pursued through the lens of legitimate 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 sham for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we agree to to erode the most exaggerated asset we have in the American healthcare system: the trust of the people we serve.
