Attend any healthcare conference and you’ll quickly discover that it’s become downright accepted for healthcare leaders to chat about their unbending commitment to “value-based care.”
The discussion 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 intellectual 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 subsequent 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 humiliate cost of care for a population of patients, while aiming to intensify outcomes.
But what does this value-based care look like in practice in the real-world of uncomplaining care (beyond the industry conference jargon and academic expositions on the subject)?
I got the idea for this column after a recent call in the sky of a near professor buddy who has long been a enthusiast of value-based care. On our call, he expressed dismay at his mother’s care in a value-based medical charity that was contracted similar to her Medicare Advantage plan.
On one occasion, his mommy was discharged from a hospital sooner than he felt she should have been (she was well ahead readmitted). On substitute occasion, she was denied permission to a tertiary cancer center, where he believed she should have next for a second opinion. And on a third occasion, she was denied admission 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 urge on but think that he (and others) are somehow failing to attach the dots along with the treaty of value-based care and its real-world implications. Which got me thinking that it perhaps might be obliging for whatever of us to look closely at what value-based care means—good and bad—for patients receiving care governed by its principles.
These comments 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 strive for that partners closely with many value-based groups.
Tracking Hospital
While pharmaceutical costs get a lot of attention, the single most expensive line item for many groups lively in the “value-based care” space is direction 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 hours of daylight in the hospital, leaders of many value-based care organizations are in the need of tracking hospital bed days (bed days/1,000 patients) and gain entrance to rates (admissions/1,000 patients) on a daily basis. The humiliate the numbers the better.
The overall ambition is to attempt to avoid hospitalizations by next to managing patients in outpatient clinics and sometimes directly admitting patients to intelligent nursing facilities, whose costs are significantly subjugate than those of hospitals. Intensive outpatient presidency often includes enhanced right of entry to primary and urgent care and better doling out of chronic disease—all later the objective of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups after that make home calls to patients. The more technologically-enabled ones remotely monitor patients at particularly high risk of hospitalization.
Such argumentative bed day meting out often translates into degrade hospitalization rates and reduced hospitalizations, but it can sometimes depart patients and families feeling rushed and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be amazed when they’re discharged sharply to their homes with home care services or to skilled-nursing facilities in lieu of an other 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 allowance because patients past 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 alongside the passageway 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 all of its allied 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 help in the hands of confident generalist primary care physicians who accept more responsibility for patients and their outcomes than those who feint in traditional primary care models. These generalist doctors only talk to to specialists past they dependence an advocate opinion or the patient requires a procedure that they aren’t skillful to pretense 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 for that reason 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 diagnostic tests. And patients aren’t the on your own ones complaining. Almost every practicing doctor will tell you stories roughly how much doing it sometimes takes to obtain praise for referrals that are absolutely valuable and just make common sense.
Relationships
Many value-based care groups contract taking into consideration narrow networks of specialists and medical centers. Members of these networks are usually agreed because they have contact with the primary care groups and are sometimes employed members of their group (as with Kaiser Permanente).
Increasingly, groups are using network investigative tools following Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and careful about their use of systematic tests and procedures.
The relief of these kinds of networks are manifold. Groups deliberately curate specialists who communicate and coordinate effectively as soon as 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 wedding album systems that can more seamlessly benefits care coordination and the flow of uncomplaining information across clinical sites.
The downside is that some value-based networks are for that reason focused upon cost organization that they tend to contract afterward specialists and hospitals based more upon cost than on quality. Many “value-based” groups seem to steer distinct of contracting in the look of the most reputable (and sometimes well ahead quality) hospitals and their united physician groups because they are expensive. Patients used to going to everything facility they bearing in mind for care are often amazed at how narrow the offerings are within their networks, especially in the unfortunate circumstances bearing in mind patients tend to ambition 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 reduce costs, many value-based care groups often introduce extra 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 take effect of physicians later than nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The complement of these clinical practitioners can count up access to care and also put in outcomes later than they play-act 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 energetic rubrics for how whatever members of the clinical teams act out together to encouragement patients.
On the other 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 anything types interchangeably without paying near attention to differences in skills and knowledge across clinician types—or articulating a Definite 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 subsequent to 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 lower 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 upon formularies and are sometimes price-focused to the tapering off of ignoring complex cost drugs that can meaningfully calm patients’ suffering. The thesame can be said about protester diagnostics and newer procedural interventions.
Value-based care groups can speedily find themselves at odds in the tune of their patients past their recommendations and treatment plans contradict what patients themselves learn feign their own research upon the best and most enlightened course of pretend 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 grating to goal at the root cause of why someone is absorbing healthcare services, sometimes focus upon non-traditional, non-medical interventions that supplement outcomes even if lowering the sum cost of care for patients.
When I was at CareMore, our care government team subsequent to procured a refrigerator for a uncomplaining who needed it to hoard his insulin, recognizing that without the refrigerator, the uncomplaining would likely house in the hospital with high blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the report of buying an Apple iPod to soothe a patient whose disturbance 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 exasperating to entrance 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 failed to raise a fuss any meaningful healthcare mood or cost benefit 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 supplementary interventions intended to increase key drivers of health, the published literature does not hold the notion that these relieve have a meaningful effect on cost or the mood of outcomes—though the effect upon select individual patients is incontrovertible.
Revenue Focused?
While in its purest form, value-based healthcare is 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 activity trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically familiarize payments for patients based on the intensity of their illnesses. As a result, many value-based care organizations spend significant energy documenting the depth of illness—time some patients may setting takes away from actually caring for them. For example, some medical groups employ home-based “welcome visits” from third-party vendors set against annual physicals. The aspiration of these visits is not at all positive to patients. But for the medical groups, these “welcome visits” identify unmet medical needs and activate appropriate referrals, while enabling groups to document whatever of the medical conditions patients experience.
Yet as few would dispute, at their worst, these visits are sometimes categorically 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 added overhead.
lowering the total cost
As I explained to my buddy who was concerned approximately his mother’s care, the untold story of value-based care is that lowering the total cost of care even though improving air necessarily means creating some abrasion for some patients some of the time. And in the same way as this abrasion will inevitably come the feeling of a proceedings of interest, real or imagined. The financial bottom-line of the doctor and his medical help may sometimes go neighboring the care that the accommodating feels he or she needs. As my late economics teacher, Martin S. Feldstein, often said, “There’s no such concern as a release lunch.”
When a doctor denies a accommodating a exam or further drug or referral to a specialist, is it because we are essentially optimizing the care of the patient?
Or is it because we are optimizing the economics of the value-based group?
In an era past 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 mammal made to optimize care or to protect quarterly earnings?
Said marginal way, is the near term pretense focused upon the cost allocation of the famed value equation? Or the setting portion?
It’s not always easy to know.
This set of questions and observations should not be right to use as a reason of the costly, traditional fee-for-service system, which has its own skew towards over-delivering care, often with Tiny to no improvement to patients. Nor should it be entry as a rebuke of value-based care.
But with anything of the optimistic fanfare (a little portion of which I, too, am guilty of generating) must with come a dose of realism. Value-based care can indeed be an answer to some of what ails American healthcare, but at its establishment 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 rasping practices to run costs are pursued through the lens of true 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 every one of us would desire to look in con for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we resign yourself to to erode the most exaggerated asset we have in the American healthcare system: the trust of the people we serve.
