Attend any healthcare conference and you’ll speedily discover that it’s become downright trendy for healthcare leaders to talk about their obstinate commitment to “value-based care.”
The expression 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 scholarly 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 giving out 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 when 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 demean 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 patient care (beyond the industry conference jargon and academic expositions upon the subject)?
I got the idea for this column after a recent call behind 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 charity that was contracted as soon 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 well ahead readmitted). On unorthodox occasion, she was denied entrance 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 right of entry to a specialist who my buddy felt could have corrected an earlier, botched cataract surgery.
As my buddy decried his mother’s care experience, I couldn’t back up but think that he (and others) are somehow failing to link up the dots with the understanding of value-based care and its real-world implications. Which got me thinking that it perhaps might be cooperative for anything of us to see closely at what value-based care means—good and bad—for patients receiving care governed by its principles.
These remarks arise from my era 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 seek that partners contiguously with many value-based groups.
Tracking Hospital
While pharmaceutical costs gain a lot of attention, the single most costly line item for many groups enthusiastic 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 morning 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 entrйe rates (admissions/1,000 patients) on a daily basis. The demean the numbers the better.
The overall try is to attempt to avoid hospitalizations by contiguously managing patients in outpatient clinics and sometimes directly admitting patients to talented nursing facilities, whose costs are significantly humiliate than those of hospitals. Intensive outpatient government often includes enhanced right of entry to primary and urgent care and better giving out of chronic disease—all behind the goal of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups with make house calls to patients. The more technologically-enabled ones remotely monitor patients at particularly tall risk of hospitalization.
Such uncompromising bed day presidency often translates into subjugate hospitalization rates and reduced hospitalizations, but it can sometimes leave 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 shortly to their homes with house care services 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 ration because patients in the way of being of end-stage conditions often get admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes mood that their doctors are quickening them down the pathway of deadening care and hospice prematurely, when they themselves have a desire to save fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with all of its associated tests and systematic 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 plus in the hands of confident generalist primary care physicians who accept more responsibility for patients and their outcomes than those who play in in received primary care models. These generalist doctors only deliver to specialists taking into consideration they obsession an protester opinion or the uncomplaining requires a procedure that they aren’t adept to fake themselves.
Of course, there can be a downside. Patients who belong in the hands of specialists are sometimes delayed getting there—and can torture yourself and have poor outcomes consequently of those delays. Because of the focus upon gatekeeping, patients often locate themselves frustrated 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 lonesome ones complaining. Almost every practicing doctor will tell you stories just about how much measure it sometimes takes to obtain acclamation for referrals that are absolutely vital and just make common sense.
Relationships
Many value-based care groups contract gone narrow networks of specialists and medical centers. Members of these networks are usually selected because they have relationships with the primary care groups and are sometimes employed members of their group (as in the circulate of Kaiser Permanente).
Increasingly, groups are using network investigative tools next 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 encourage of these kinds of networks are manifold. Groups intentionally curate specialists who communicate and coordinate effectively afterward 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 tape systems that can more seamlessly assist care coordination and the flow of tolerant information across clinical sites.
The downside is that some value-based networks are correspondingly focused on cost dispensation that they tend to contract once specialists and hospitals based more on cost than upon quality. Many “value-based” groups seem to steer positive of contracting bearing in mind the most reputable (and sometimes well along quality) hospitals and their joined physician groups because they are expensive. Patients used to going to all facility they taking into account for care are often surprised at how narrow the offerings are within their networks, especially in the unfortunate circumstances in imitation of patients tend to mean 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 cut 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 summit of the license.” In practice, it means groups adjunct the work of physicians next nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The auxiliary of these clinical practitioners can combine access to care and also adjoin outcomes later than they behave 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 sure and functioning rubrics for how everything members of the clinical teams bill together to support patients.
On the further hand, patients who want to look physicians—or, sometimes, need to look physicians—often get frustrated that permission to generalist physicians (and specialists) might be limited by non-physician gatekeepers. What’s more, the worst value-based care groups use professionals of everything types interchangeably without paying near attention to differences in skills and knowledge across clinician types—or articulating a sure 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 take forward of the formularies they employ for the care of patients.
In practice, this means they tend to favor drugs when 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 further drugs upon formularies and are sometimes price-focused to the tapering off of ignoring forward-looking cost drugs that can meaningfully put to rest patients’ suffering. The same can be said about radical diagnostics and newer procedural interventions.
Value-based care groups can quickly find themselves at odds subsequent to their patients past their recommendations and treatment plans contradict what patients themselves learn feint their own research upon the best and most enlightened course of take action 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 exasperating to dream at the root cause of why someone is consuming healthcare services, sometimes focus upon non-traditional, non-medical interventions that affix outcomes though lowering the total cost of care for patients.
When I was at CareMore, our care presidency team once procured a refrigerator for a compliant who needed it to buildup his insulin, recognizing that without the refrigerator, the compliant would likely estate 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 accommodating whose campaigning led him to the emergency room greater than 100 epoch 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 aggravating to permission 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 excite any meaningful healthcare tone or cost pro 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 additional interventions designed to increase key drivers of health, the published literature does not preserve the notion that these relieve have a meaningful effect on 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 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 life trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically adapt payments for patients based on the depth of their illnesses. As a result, many value-based care organizations spend significant cartoon documenting the severity of illness—time some patients may atmosphere takes away from actually caring for them. For example, some medical groups employ home-based “welcome visits” from third-party vendors disaffect annual physicals. The purpose of these visits is not at all determined to patients. But for the medical groups, these “welcome visits” identify unmet medical needs and get going 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 utterly divorced from a patient’s care and sustain exclusively to maximize the payments groups receive from payers. These types of visits are often regarded as non-value further overhead.
lowering the sum cost
As I explained to my buddy who was concerned about his mother’s care, the untold bank account of value-based care is that lowering the sum cost of care though 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 act of interest, real or imagined. The financial bottom-line of the doctor and his medical action may sometimes go against the care that the accommodating feels he or she needs. As my late economics teacher, Martin S. Feldstein, often said, “There’s no such matter as a free lunch.”
When a doctor denies a uncomplaining a test or additional drug or referral to a specialist, is it because we are in reality optimizing the care of the patient?
Or is it because we are optimizing the economics of the value-based group?
In an era similar 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 other pharmaceutical instinctive made to optimize care or to protect quarterly earnings?
Said choice way, is the close term measure focused upon the cost share of the famed value equation? Or the character portion?
It’s not always easy to know.
This set of questions and interpretation 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 admittance as a warn about of value-based care.
But with everything of the optimistic fanfare (a small portion of which I, too, am guilty of generating) must then 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 pull off 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 coarse practices to govern costs are pursued through the lens of real benefit to the patient, not the financial interests of the group. The happenings to which we subject patients must be guided by the “radical common sense” that all one of us would desire to see in take action for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we acknowledge to erode the most unnatural asset we have in the American healthcare system: the trust of the people we serve.
