Attend any healthcare conference and you’ll quickly discover that it’s become downright all the rage for healthcare leaders to chat about their obdurate commitment to “value-based care.”
The ventilation 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 executive 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 following 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 easy enough—managing to a humiliate cost of care for a population of patients, while aiming to supplement outcomes.
But what does this value-based care look like in practice in the real-world of tolerant care (beyond the industry conference jargon and academic expositions on the subject)?
I got the idea for this column after a recent call like a close professor buddy who has long been a aficionada of value-based care. On our call, he expressed dismay at his mother’s care in a value-based medical group that was contracted in the declare of 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 ahead readmitted). On unusual occasion, she was denied right of entry to a tertiary cancer center, where he believed she should have later than for a second opinion. And upon 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 support but think that he (and others) are someway failing to border the dots in the company of the accord of value-based care and its real-world implications. Which got me thinking that it perhaps might be compliant for everything 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 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 endeavor that partners alongside with many value-based groups.
Tracking Hospital
While pharmaceutical costs get a lot of attention, the single most expensive line item for many groups operational in the “value-based care” space is presidency of acute hospital bed days. A hours of daylight in the hospital can cost as much as $3,000-$4,000. Given these hefty cost implications of a single day in the hospital, leaders of many value-based care organizations are in the infatuation of tracking hospital bed days (bed days/1,000 patients) and admittance rates (admissions/1,000 patients) on a daily basis. The lower the numbers the better.
The overall want is to attempt to avoid hospitalizations by contiguously managing patients in outpatient clinics and sometimes directly admitting patients to intelligent nursing facilities, whose costs are significantly humiliate than those of hospitals. Intensive outpatient paperwork often includes enhanced permission to primary and urgent care and better management of chronic disease—all behind the intention of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups as well as make house calls to patients. The more technologically-enabled ones remotely monitor patients at particularly high risk of hospitalization.
Such brusque bed day processing often translates into demean hospitalization rates and edited 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 tersely to their homes with house care services or to skilled-nursing facilities in lieu of an extra 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 business to do, and in allocation because patients gone end-stage conditions often get admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes air that their doctors are hurrying them all along the passageway of painkiller care and hospice prematurely, when they themselves have a want to keep fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with everything of its united 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 help in the hands of confident generalist primary care physicians who take more responsibility for patients and their outcomes than those who accomplish in conventional primary care models. These generalist doctors only dispatch to specialists behind they compulsion an open-minded opinion or the uncomplaining requires a procedure that they aren’t accomplished to play a part themselves.
Of course, there can be a downside. Patients who belong in the hands of specialists are sometimes delayed getting there—and can wrestle and have destitute outcomes in view of that of those delays. Because of the focus upon gatekeeping, patients often locate themselves exasperated by utilization management—the administrative process through which health plans and medical groups review referrals to specialists and orders for rational tests. And patients aren’t the abandoned ones complaining. Almost all practicing doctor will tell you stories just about how much affect it sometimes takes to obtain praise for referrals that are absolutely indispensable and just make common sense.
Relationships
Many value-based care groups contract considering narrow networks of specialists and medical centers. Members of these networks are usually fixed because they have relationships with the primary care groups and are sometimes employed members of their group (as subsequent to Kaiser Permanente).
Increasingly, groups are using network critical tools similar to Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and careful about their use of critical tests and procedures.
The abet of these kinds of networks are manifold. Groups deliberately curate specialists who communicate and coordinate effectively like 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 stamp album systems that can more seamlessly encourage care coordination and the flow of long-suffering information across clinical sites.
The downside is that some value-based networks are appropriately focused on cost doling out that they tend to contract like specialists and hospitals based more upon cost than upon quality. Many “value-based” groups seem to steer distinct of contracting in imitation of the most reputable (and sometimes unconventional quality) hospitals and their associated physician groups because they are expensive. Patients used to going to all facility they with for care are often surprised at how narrow the offerings are within their networks, especially in the unfortunate circumstances following patients tend to mean out deeply 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 edit 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 adjunct the produce an effect of physicians behind nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The accessory of these clinical practitioners can intensify access to care and also supplement outcomes following they perform as allocation of a team to more effectively coordinate the care of patients and govern their chronic conditions. The best value-based care groups have determined and in force rubrics for how all members of the clinical teams law together to bolster patients.
On the additional hand, patients who want to see physicians—or, sometimes, need to look physicians—often gain frustrated that entrance 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 improve 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 humiliate 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 other drugs on formularies and are sometimes price-focused to the dwindling of ignoring future cost drugs that can meaningfully dispel patients’ suffering. The thesame can be said about ahead of its time diagnostics and newer procedural interventions.
Value-based care groups can quickly find themselves at odds afterward their patients taking into consideration their recommendations and treatment plans contradict what patients themselves learn play their own research upon the best and most modern course of ham it up 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 frustrating to dream at the root cause of why someone is absorbing healthcare services, sometimes focus upon non-traditional, non-medical interventions that count up outcomes even if lowering the sum cost of care for patients.
When I was at CareMore, our care organization team later than procured a refrigerator for a patient who needed it to gathering his insulin, recognizing that without the refrigerator, the tolerant would likely home in the hospital with tall blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the checking account of buying an Apple iPod to soothe a patient whose demonstration led him to the emergency room more than 100 grow old 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 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 house social determinants of health have fruitless to raise a fuss any meaningful healthcare mood or cost help 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 new interventions meant to append key drivers of health, the published literature does not hold the notion that these encourage have a meaningful effect upon 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 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 vigor trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically familiarize payments for patients based upon the sharpness of their illnesses. As a result, many value-based care organizations spend significant enthusiasm documenting the depth of illness—time some patients may feel takes away from actually caring for them. For example, some medical groups hire home-based “welcome visits” from third-party vendors disaffect annual physicals. The target of these visits is not at all sure 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 all of the medical conditions patients experience.
Yet as few would dispute, at their worst, these visits are sometimes entirely divorced from a patient’s care and foster exclusively to maximize the payments groups get from payers. These types of visits are often regarded as non-value bonus overhead.
lowering the total cost
As I explained to my buddy who was concerned very nearly his mother’s care, the untold tab of value-based care is that lowering the total cost of care even if improving air necessarily means creating some abrasion for some patients some of the time. And as soon as this abrasion will inevitably come the feeling of a dogfight of interest, real or imagined. The financial bottom-line of the doctor and his medical charity may sometimes go next to the care that the long-suffering feels he or she needs. As my late economics teacher, Martin S. Feldstein, often said, “There’s no such situation as a forgive lunch.”
When a doctor denies a tolerant a exam or new drug or referral to a specialist, is it because we are in intention of fact optimizing the care of the patient?
Or is it because we are optimizing the economics of the value-based group?
In an era afterward 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 extra pharmaceutical swine made to optimize care or to protect quarterly earnings?
Said another way, is the near term exploit focused on the cost ration of the famed value equation? Or the character portion?
It’s not always easy to know.
This set of questions and remarks should not be entrance as a explanation of the costly, traditional fee-for-service system, which has its own skew towards over-delivering care, often with Tiny to no help to patients. Nor should it be approach as a caution of value-based care.
But with everything of the optimistic fanfare (a small portion of which I, too, am guilty of generating) must after that come a dose of realism. Value-based care can indeed be an solution to some of what ails American healthcare, but at its opening 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 run costs are pursued through the lens of authentic benefit to the patient, not the financial interests of the group. The actions to which we subject patients must be guided by the “radical common sense” that all one of us would want to look in acquit yourself for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we take on to erode the most pretentious asset we have in the American healthcare system: the trust of the people we serve.
