Attend any healthcare conference and you’ll speedily discover that it’s become downright trendy for healthcare leaders to talk about their steadfast 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 scholastic 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 supervision 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 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 attach outcomes.
But what does this value-based care see like in practice in the real-world of patient care (beyond the industry conference jargon and academic expositions on the subject)?
I got the idea for this column after a recent call behind a near professor buddy 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 work that was contracted past her Medicare Advantage plan.
On one occasion, his mother was discharged from a hospital sooner than he felt she should have been (she was difficult readmitted). On substitute occasion, she was denied right of entry to a tertiary cancer center, where he believed she should have taking into consideration for a second opinion. And upon a third occasion, she was denied admission to a specialist who my friend 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 anyhow failing to connect the dots amongst the concurrence of value-based care and its real-world implications. Which got me thinking that it perhaps might be helpful for all of us to see closely at what value-based care means—good and bad—for patients receiving care governed by its principles.
These interpretation arise from my get older 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 purpose that partners to the side of with many value-based groups.
Tracking Hospital
While pharmaceutical costs gain a lot of attention, the single most expensive line item for many groups in force 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 compulsion of tracking hospital bed days (bed days/1,000 patients) and edit rates (admissions/1,000 patients) on a daily basis. The degrade the numbers the better.
The overall plan is to try to avoid hospitalizations by closely managing patients in outpatient clinics and sometimes directly admitting patients to capable nursing facilities, whose costs are significantly lower than those of hospitals. Intensive outpatient government often includes enhanced right of entry to primary and urgent care and better government of chronic disease—all later than the want 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 rude bed day organization often translates into lower hospitalization rates and reduced hospitalizations, but it can sometimes depart patients and families feeling quick 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 home care facilities or to skilled-nursing services in lieu of an further 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 concern to do, and in allocation because patients like end-stage conditions often get admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes character that their doctors are speeding up them all along the lane 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 allied tests and questioning 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 plus in the hands of confident generalist primary care physicians who accept more responsibility for patients and their outcomes than those who measure in customary primary care models. These generalist doctors only tackle to specialists behind they dependence an forward looking opinion or the tolerant requires a procedure that they aren’t dexterous to deed themselves.
Of course, there can be a downside. Patients who belong in the hands of specialists are sometimes delayed getting there—and can be anxious and have destitute outcomes therefore of those delays. Because of the focus on gatekeeping, patients often find themselves incensed by utilization management—the administrative process through which health plans and medical groups review referrals to specialists and orders for reasoned tests. And patients aren’t the unaided ones complaining. Almost every practicing doctor will tell you stories not quite how much play it sometimes takes to obtain acclamation 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 chosen because they have associations with the primary care groups and are sometimes employed members of their group (as behind Kaiser Permanente).
Increasingly, groups are using network systematic tools gone Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and cautious about their use of critical tests and procedures.
The assistance of these kinds of networks are manifold. Groups with intent curate specialists who communicate and coordinate effectively next 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 on common electronic health sticker album systems that can more seamlessly abet care coordination and the flow of tolerant information across clinical sites.
The downside is that some value-based networks are therefore focused upon cost meting out that they tend to contract next specialists and hospitals based more upon cost than upon quality. Many “value-based” groups seem to steer Definite of contracting as soon as the most reputable (and sometimes highly developed quality) hospitals and their joined physician groups because they are expensive. Patients used to going to everything facility they past for care are often surprised at how narrow the offerings are within their networks, especially in the unfortunate circumstances similar to patients tend to point toward out severely 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 further 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 adjunct the accomplish of physicians past nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The accessory of these clinical practitioners can improve access to care and also count up outcomes taking into consideration they bill as share of a team to more effectively coordinate the care of patients and manage their chronic conditions. The best value-based care groups have positive and full of life rubrics for how all members of the clinical teams put it on together to further patients.
On the extra hand, patients who want to see physicians—or, sometimes, need to look 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 whatever types interchangeably without paying close 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 move forward of the formularies they employ for the care of patients.
In practice, this means they tend to favor drugs afterward 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 subjugate 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 extra drugs upon formularies and are sometimes price-focused to the point of ignoring far ahead cost drugs that can meaningfully put to rest patients’ suffering. The same can be said about objector diagnostics and newer procedural interventions.
Value-based care groups can quickly find themselves at odds similar to their patients in the manner of their recommendations and treatment plans contradict what patients themselves learn put-on their own research on the best and most unprejudiced course of acquit yourself 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 aspiration at the root cause of why someone is absorbing healthcare services, sometimes focus upon non-traditional, non-medical interventions that count up outcomes while lowering the sum cost of care for patients.
When I was at CareMore, our care handing out team subsequently procured a refrigerator for a tolerant who needed it to stock his insulin, recognizing that without the refrigerator, the tolerant would likely home in the hospital with high blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the balance of buying an Apple iPod to soothe a long-suffering whose stir led him to the emergency room beyond 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 irritating 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 address social determinants of health have fruitless to stir any meaningful healthcare tone or cost lead to the programs.
What’s more, while many value-based care organizations (including two I have led) provide permission to gym benefits, transportation, food, and further interventions meant to count key drivers of health, the published literature does not maintain the notion that these help have a meaningful effect upon cost or the character 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 sum cost of care by ensuring that patients are healthier and are making judicious use of the healthcare system, many organizations spend significant dynamism trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically acclimatize payments for patients based on the intensity of their illnesses. As a result, many value-based care organizations spend significant vigor documenting the extremity of illness—time some patients may mood takes away from actually caring for them. For example, some medical groups hire home-based “welcome visits” from third-party vendors keep apart from annual physicals. The aspiration of these visits is not at all Definite to patients. But for the medical groups, these “welcome visits” identify unmet medical needs and trigger appropriate referrals, while enabling groups to document all of the medical conditions patients experience.
Yet as few would dispute, at their worst, these visits are sometimes completely divorced from a patient’s care and utility 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 very nearly his mother’s care, the untold report of value-based care is that lowering the total cost of care even though improving setting necessarily means creating some abrasion for some patients some of the time. And past 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 charity may sometimes go against the care that the compliant feels he or she needs. As my late economics teacher, Martin S. Feldstein, often said, “There’s no such thing as a pardon lunch.”
When a doctor denies a long-suffering a test or supplementary 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 subsequent to 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 being made to optimize care or to guard quarterly earnings?
Said marginal way, is the near term accomplish focused on the cost ration of the famed value equation? Or the quality portion?
It’s not always easy to know.
This set of questions and clarification should not be entrance as a defense of the costly, traditional fee-for-service system, which has its own skew towards over-delivering care, often with little to no gain to patients. Nor should it be open as a scold of value-based care.
But with anything of the optimistic fanfare (a small portion of which I, too, am guilty of generating) must with come a dose of realism. Value-based care can indeed be an solution to some of what ails American healthcare, but at its initiation there must be something somewhat increasingly quaint and elusive:
An ethical underpinning to always attain 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 unfriendly practices to manage costs are pursued through the lens of real benefit to the patient, not the financial interests of the group. The endeavors to which we subject patients must be guided by the “radical common sense” that all one of us would desire to look in conduct yourself for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we put taking place with to erode the most artificial asset we have in the American healthcare system: the trust of the people we serve.
