Attend any healthcare conference and you’ll quickly discover that it’s become downright in style for healthcare leaders to talk about their resolute commitment to “value-based care.”
The exposure 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 teacher 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 doling 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 taking into consideration 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 belittle cost of care for a population of patients, while aiming to include outcomes.
But what does this value-based care see 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 later 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 activity that was contracted bearing in mind her Medicare Advantage plan.
On one occasion, his mother was discharged from a hospital sooner than he felt she should have been (she was forward-looking readmitted). On other occasion, she was denied right of entry 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 permission to a specialist who my friend felt could have corrected an earlier, botched cataract surgery.
As my buddy decried his mother’s care experience, I couldn’t assist but think that he (and others) are anyhow failing to be oppressive to the dots between the concord of value-based care and its real-world implications. Which got me thinking that it perhaps might be long-suffering 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 clarification arise from my period 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 direct that partners contiguously with many value-based groups.
Tracking Hospital
While pharmaceutical costs get a lot of attention, the single most costly line item for many groups operational in the “value-based care” space is organization 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 daylight 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 door rates (admissions/1,000 patients) on a daily basis. The degrade the numbers the better.
The overall direct is to attempt to avoid hospitalizations by nearby managing patients in outpatient clinics and sometimes directly admitting patients to adept nursing facilities, whose costs are significantly belittle than those of hospitals. Intensive outpatient supervision often includes enhanced permission to primary and urgent care and better admin of chronic disease—all bearing in mind the endeavor of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups in addition to make house calls to patients. The more technologically-enabled ones remotely monitor patients at particularly high risk of hospitalization.
Such unfriendly bed day paperwork often translates into subjugate hospitalization rates and reduced hospitalizations, but it can sometimes leave patients and families feeling short and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be amazed when they’re discharged rapidly 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 matter to do, and in share 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 setting that their doctors are rushing them by the side of the passage of palliative care and hospice prematurely, when they themselves have a want to save fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with all of its associated tests and rational procedures—can be expensive. In fee-for-service environments, primary care physicians often forward 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 lead in the hands of confident generalist primary care physicians who take more liability for patients and their outcomes than those who accomplishment in standard primary care models. These generalist doctors only forward to specialists past they habit an militant opinion or the accommodating requires a procedure that they aren’t clever to be active themselves.
Of course, there can be a downside. Patients who belong in the hands of specialists are sometimes delayed getting there—and can torment yourself and have destitute outcomes so of those delays. Because of the focus upon gatekeeping, patients often locate themselves enraged 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 unaided ones complaining. Almost every practicing doctor will tell you stories more or less how much action it sometimes takes to obtain commend for referrals that are absolutely essential 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 relationships with the primary care groups and are sometimes employed members of their group (as bearing in mind Kaiser Permanente).
Increasingly, groups are using network questioning tools later Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and cautious about their use of reasoned tests and procedures.
The support of these kinds of networks are manifold. Groups on purpose curate specialists who communicate and coordinate effectively subsequently 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 baby book systems that can more seamlessly assistance 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 subsequently specialists and hospitals based more on cost than upon quality. Many “value-based” groups seem to steer certain of contracting following the most reputable (and sometimes well along quality) hospitals and their united physician groups because they are expensive. Patients used to going to everything facility they when for care are often amazed at how narrow the offerings are within their networks, especially in the unfortunate circumstances like patients tend to endeavor out severely specialized care facilities (i.e. cancer centers) and specialists.
In addition, some patients locate 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 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 addition the feign of physicians afterward nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The addition of these clinical practitioners can tally up access to care and also add together outcomes subsequent to they produce an effect as part of a team to more effectively coordinate the care of patients and rule their chronic conditions. The best value-based care groups have Definite and in action rubrics for how everything members of the clinical teams undertaking together to foster patients.
On the new hand, patients who desire to see physicians—or, sometimes, need to look physicians—often get frustrated that admission 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 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 increase of the formularies they employ for the care of patients.
In practice, this means they tend to favor drugs in imitation of 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 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 other drugs on formularies and are sometimes price-focused to the narrowing of ignoring complex cost drugs that can meaningfully calm patients’ suffering. The same can be said about unbiased diagnostics and newer procedural interventions.
Value-based care groups can quickly find themselves at odds later than their patients in the tune of their recommendations and treatment plans contradict what patients themselves learn doing their own research upon the best and most advanced course of take effect 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 a pain to aspiration at the root cause of why someone is absorbing healthcare services, sometimes focus on non-traditional, non-medical interventions that adjoin outcomes though lowering the total cost of care for patients.
When I was at CareMore, our care doling out team behind procured a refrigerator for a patient who needed it to growth his insulin, recognizing that without the refrigerator, the compliant would likely home in the hospital with tall blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the relation of buying an Apple iPod to soothe a long-suffering whose tension led him to the emergency room greater than 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 bothersome to access 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 quarters social determinants of health have fruitless to stir up opinion any meaningful healthcare vibes 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 further interventions intended to tally key drivers of health, the published literature does not maintain the notion that these help have a meaningful effect upon cost or the environment of outcomes—though the effect on select individual patients is incontrovertible.
Revenue Focused?
While in its purest form, value-based healthcare is roughly 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 vivaciousness trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically adjust payments for patients based upon the intensity of their illnesses. As a result, many value-based care organizations spend significant cartoon documenting the depth of illness—time some patients may atmosphere takes away from actually caring for them. For example, some medical groups hire home-based “welcome visits” from third-party vendors turn your back on annual physicals. The target of these visits is not at all distinct to patients. But for the medical groups, these “welcome visits” identify unmet medical needs and put into action appropriate referrals, while enabling groups to document anything of the medical conditions patients experience.
Yet as few would dispute, at their worst, these visits are sometimes certainly divorced from a patient’s care and minister to exclusively to maximize the payments groups receive from payers. These types of visits are often regarded as non-value supplementary overhead.
lowering the total cost
As I explained to my friend who was concerned approximately his mother’s care, the untold checking account of value-based care is that lowering the sum cost of care while improving setting necessarily means creating some abrasion for some patients some of the time. And later than this abrasion will inevitably come the feeling of a accomplishment of interest, real or imagined. The financial bottom-line of the doctor and his medical outfit may sometimes go adjacent to the care that the patient feels he or she needs. As my late economics teacher, Martin S. Feldstein, often said, “There’s no such thing as a free lunch.”
When a doctor denies a uncomplaining a exam or extra 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 supplementary pharmaceutical living thing made to optimize care or to protect quarterly earnings?
Said another way, is the close term doing focused upon the cost ration of the famed value equation? Or the feel portion?
It’s not always easy to know.
This set of questions and comments should not be open as a reason 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 get into as a chide of value-based care.
But with anything of the optimistic fanfare (a small portion of which I, too, am guilty of generating) must next 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 accomplish 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 uncompromising practices to direct costs are pursued through the lens of legal 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 see in piece of legislation for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we say yes to erode the most exaggerated asset we have in the American healthcare system: the trust of the people we serve.
