Attend any healthcare conference and you’ll speedily discover that it’s become downright accepted for healthcare leaders to talk about their inflexible commitment to “value-based care.”
The trip out 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 studious 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 running 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 later 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 easy enough—managing to a belittle cost of care for a population of patients, while aiming to augment outcomes.
But what does this value-based care look like in practice in the real-world of compliant care (beyond the industry conference jargon and academic expositions on the subject)?
I got the idea for this column after a recent call next a close professor friend who has long been a devotee of value-based care. On our call, he expressed dismay at his mother’s care in a value-based medical bureau that was contracted in the same way as her Medicare Advantage plan.
On one occasion, his mommy was discharged from a hospital sooner than he felt she should have been (she was vanguard readmitted). On substitute occasion, she was denied access 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 right of 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 incite but think that he (and others) are someway failing to attach the dots amongst the concord 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 see closely at what value-based care means—good and bad—for patients receiving care governed by its principles.
These explanation 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 aspiration that partners nearby with many value-based groups.
Tracking Hospital
While pharmaceutical costs gain a lot of attention, the single most expensive line item for many groups functioning 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 retrieve rates (admissions/1,000 patients) on a daily basis. The humiliate the numbers the better.
The overall plan is to attempt to avoid hospitalizations by alongside managing patients in outpatient clinics and sometimes directly admitting patients to competent nursing facilities, whose costs are significantly demean than those of hospitals. Intensive outpatient running often includes enhanced entry to primary and urgent care and better meting out of chronic disease—all once the purpose of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups also make home calls to patients. The more technologically-enabled ones remotely monitor patients at particularly tall risk of hospitalization.
Such coarse bed day organization often translates into belittle hospitalization rates and shortened hospitalizations, but it can sometimes leave patients and families feeling unexpected and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be surprised when they’re discharged hurriedly to their homes with home care services or to skilled-nursing facilities in lieu of an supplementary few nights in the hospital.
In addition, many value-based care groups prioritize pain reliever care and proactively transition patients to hospice—in part, because it’s often the right business to do, and in allocation 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 atmosphere that their doctors are increase in speed them the length of 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 everything of its united tests and reasoned procedures—can be expensive. In fee-for-service environments, primary care physicians often deliver 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 improvement in the hands of confident generalist primary care physicians who take more liability for patients and their outcomes than those who affect in established primary care models. These generalist doctors only deal with to specialists subsequent to they craving an highly developed opinion or the accommodating requires a procedure that they aren’t accomplished to undertaking themselves.
Of course, there can be a downside. Patients who belong in the hands of specialists are sometimes delayed getting there—and can dwell on and have poor outcomes appropriately 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 diagnostic tests. And patients aren’t the unaccompanied ones complaining. Almost every practicing doctor will say you stories virtually how much comport yourself it sometimes takes to obtain compliments for referrals that are absolutely critical and just make common sense.
Relationships
Many value-based care groups contract with narrow networks of specialists and medical centers. Members of these networks are usually prearranged because they have dealings with the primary care groups and are sometimes employed members of their group (as past Kaiser Permanente).
Increasingly, groups are using network methodical tools when 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 bolster of these kinds of networks are manifold. Groups with intent curate specialists who communicate and coordinate effectively subsequent to 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 CD systems that can more seamlessly advance care coordination and the flow of long-suffering information across clinical sites.
The downside is that some value-based networks are hence focused on cost organization that they tend to contract similar to specialists and hospitals based more upon cost than on quality. Many “value-based” groups seem to steer sure of contracting in imitation of the most reputable (and sometimes forward-looking quality) hospitals and their united physician groups because they are expensive. Patients used to going to all facility they considering for care are often surprised at how narrow the offerings are within their networks, especially in the unfortunate circumstances bearing in mind patients tend to point toward out extremely 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 abbreviate costs, many value-based care groups often introduce other 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 addition the play a part of physicians taking into consideration nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The complement of these clinical practitioners can swell access to care and also supplement outcomes later than they operate as allocation of a team to more effectively coordinate the care of patients and control their chronic conditions. The best value-based care groups have distinct and in action rubrics for how anything members of the clinical teams play in together to relief patients.
On the supplementary hand, patients who want 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 all types interchangeably without paying close 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 onslaught of the formularies they hire for the care of patients.
In practice, this means they tend to favor drugs in the same way as 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 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 supplementary drugs on formularies and are sometimes price-focused to the lessening of ignoring future cost drugs that can meaningfully alleviate patients’ suffering. The similar can be said about unprejudiced diagnostics and newer procedural interventions.
Value-based care groups can speedily find themselves at odds afterward their patients in imitation of their recommendations and treatment plans contradict what patients themselves learn play-act their own research upon the best and most innovative course of do its stuff 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 exasperating to aspiration at the root cause of why someone is consuming healthcare services, sometimes focus on non-traditional, non-medical interventions that count outcomes while lowering the sum cost of care for patients.
When I was at CareMore, our care dispensation team later procured a refrigerator for a uncomplaining who needed it to collection 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 balance of buying an Apple iPod to soothe a tolerant whose worry led him to the emergency room over 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 grating 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 residence social determinants of health have futile to disconcert any meaningful healthcare quality or cost benefit 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 other interventions meant to complement key drivers of health, the published literature does not support the notion that these utility have a meaningful effect on cost or the atmosphere of outcomes—though the effect on select individual patients is incontrovertible.
Revenue Focused?
While in its purest form, value-based healthcare is very nearly 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 severity of their illnesses. As a result, many value-based care organizations spend significant activity documenting the sharpness 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 make unfriendly annual physicals. The endeavor of these visits is not at all determined to patients. But for the medical groups, these “welcome visits” identify unmet medical needs and activate 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 very divorced from a patient’s care and further exclusively to maximize the payments groups receive from payers. These types of visits are often regarded as non-value bonus overhead.
lowering the total cost
As I explained to my friend who was concerned more or less his mother’s care, the untold tally of value-based care is that lowering the sum cost of care even if improving setting necessarily means creating some abrasion for some patients some of the time. And following this abrasion will inevitably come the feeling of a prosecution of interest, real or imagined. The financial bottom-line of the doctor and his medical outfit 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 event as a pardon lunch.”
When a doctor denies a long-suffering a test or further 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 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 additional pharmaceutical subconscious made to optimize care or to protect quarterly earnings?
Said substitute way, is the near term statute focused on the cost ration 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 gate 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 lead to patients. Nor should it be entrйe as a reproach of value-based care.
But with everything of the optimistic fanfare (a small 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 answer to some of what ails American healthcare, but at its introduction there must be something somewhat increasingly quaint and elusive:
An ethical underpinning to always complete 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 authentic benefit to the patient, not the financial interests of the group. The goings-on to which we subject patients must be guided by the “radical common sense” that every one of us would want to look in proceed 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.
