Attend any healthcare conference and you’ll speedily discover that it’s become downright trendy for healthcare leaders to chat about their immovable commitment to “value-based care.”
The excursion 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 scholastic 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 government 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 in imitation of 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 subjugate cost of care for a population of patients, while aiming to complement outcomes.
But what does this value-based care look like in practice in the real-world of accommodating care (beyond the industry conference jargon and academic expositions on the subject)?
I got the idea for this column after a recent call past a near professor friend who has long been a follower of value-based care. On our call, he expressed dismay at his mother’s care in a value-based medical outfit that was contracted in imitation of her Medicare Advantage plan.
On one occasion, his mommy was discharged from a hospital sooner than he felt she should have been (she was forward-looking readmitted). On another occasion, she was denied access to a tertiary cancer center, where he believed she should have in the same way as for a second opinion. And upon 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 incite but think that he (and others) are somehow failing to be stuffy to the dots surrounded by the treaty of value-based care and its real-world implications. Which got me thinking that it perhaps might be cooperative 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 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 try that partners alongside with many value-based groups.
Tracking Hospital
While pharmaceutical costs gain a lot of attention, the single most expensive line item for many groups vigorous in the “value-based care” space is presidency 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 craving of tracking hospital bed days (bed days/1,000 patients) and edit rates (admissions/1,000 patients) on a daily basis. The subjugate the numbers the better.
The overall ambition is to try to avoid hospitalizations by to the side of managing patients in outpatient clinics and sometimes directly admitting patients to clever nursing facilities, whose costs are significantly demean than those of hospitals. Intensive outpatient dispensation often includes enhanced permission to primary and urgent care and better dispensation of chronic disease—all taking into account the wish of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups afterward make home calls to patients. The more technologically-enabled ones remotely monitor patients at particularly tall risk of hospitalization.
Such aggressive bed day government often translates into demean hospitalization rates and shortened hospitalizations, but it can sometimes depart patients and families feeling brusque and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be surprised when they’re discharged rudely to their homes with house 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 pain-relieving care and proactively transition patients to hospice—in part, because it’s often the right situation to do, and in part because patients like end-stage conditions often get admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes quality that their doctors are increase in speed them by the side of the passage of pain reliever care and hospice prematurely, when they themselves have a want to save fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with anything of its united tests and questioning procedures—can be expensive. In fee-for-service environments, primary care physicians often dispatch 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 gain in the hands of confident generalist primary care physicians who accept more liability for patients and their outcomes than those who play in in standard primary care models. These generalist doctors only adopt to specialists subsequently they infatuation an advocate opinion or the compliant requires a procedure that they aren’t practiced to pretend 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 as a result of those delays. Because of the focus on gatekeeping, patients often locate themselves incensed 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 without help ones complaining. Almost all practicing doctor will tell you stories practically how much put-on it sometimes takes to obtain applaud for referrals that are absolutely critical and just make common sense.
Relationships
Many value-based care groups contract subsequently narrow networks of specialists and medical centers. Members of these networks are usually chosen because they have interaction with the primary care groups and are sometimes employed members of their group (as once Kaiser Permanente).
Increasingly, groups are using network analytic tools subsequent to Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and cautious about their use of rational tests and procedures.
The minister to of these kinds of networks are manifold. Groups deliberately curate specialists who communicate and coordinate effectively later than 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 compilation systems that can more seamlessly abet care coordination and the flow of uncomplaining information across clinical sites.
The downside is that some value-based networks are thus focused upon cost government that they tend to contract once specialists and hospitals based more on cost than on quality. Many “value-based” groups seem to steer sure of contracting following the most reputable (and sometimes progressive quality) hospitals and their joined physician groups because they are expensive. Patients used to going to everything facility they taking into consideration for care are often amazed at how narrow the offerings are within their networks, especially in the unfortunate circumstances taking into consideration patients tend to aspiration 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 shorten costs, many value-based care groups often introduce supplementary 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 auxiliary the doing of physicians in the same way as nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The adjunct of these clinical practitioners can intensify access to care and also augment outcomes in the announce of they action as allowance of a team to more effectively coordinate the care of patients and direct their chronic conditions. The best value-based care groups have distinct and lively rubrics for how whatever members of the clinical teams discharge duty together to give foster to patients.
On the extra hand, patients who desire to see physicians—or, sometimes, need to see physicians—often gain frustrated that entry 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 clear 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 enhance of the formularies they employ for the care of patients.
In practice, this means they tend to favor drugs like 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 additional drugs on formularies and are sometimes price-focused to the tapering off of ignoring progressive cost drugs that can meaningfully relieve patients’ suffering. The similar can be said about unbiased diagnostics and newer procedural interventions.
Value-based care groups can quickly find themselves at odds in imitation of their patients later than their recommendations and treatment plans contradict what patients themselves learn action their own research upon the best and most futuristic course of feat 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 irritating to motivation at the root cause of why someone is consuming healthcare services, sometimes focus on non-traditional, non-medical interventions that complement outcomes while lowering the total cost of care for patients.
When I was at CareMore, our care handing out team similar to procured a refrigerator for a long-suffering who needed it to collection his insulin, recognizing that without the refrigerator, the long-suffering would likely house in the hospital with tall blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the savings account of buying an Apple iPod to soothe a compliant whose stir led him to the emergency room more 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 trying 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 domicile social determinants of health have unproductive to stir up any meaningful healthcare atmosphere or cost plus 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 further interventions meant to attach key drivers of health, the published literature does not preserve the notion that these help 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 not quite 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 accustom yourself payments for patients based on the extremity of their illnesses. As a result, many value-based care organizations spend significant vibrancy documenting the height of illness—time some patients may tone 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 direct of these visits is not at all Definite to patients. But for the medical groups, these “welcome visits” identify unmet medical needs and motivate 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 extremely divorced from a patient’s care and support exclusively to maximize the payments groups receive from payers. These types of visits are often regarded as non-value bonus overhead.
lowering the sum cost
As I explained to my buddy who was concerned virtually his mother’s care, the untold checking account of value-based care is that lowering the sum cost of care even if improving feel necessarily means creating some abrasion for some patients some of the time. And when this abrasion will inevitably come the feeling of a achievement of interest, real or imagined. The financial bottom-line of the doctor and his medical intervention may sometimes go against the care that the patient feels he or she needs. As my late economics teacher, Martin S. Feldstein, often said, “There’s no such matter as a forgive lunch.”
When a doctor denies a long-suffering a exam or other 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 as soon as 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 being made to optimize care or to guard quarterly earnings?
Said substitute way, is the close term put on an act focused on the cost allowance of the famed value equation? Or the air portion?
It’s not always simple to know.
This set of questions and interpretation should not be admittance as a excuse of the costly, traditional fee-for-service system, which has its own skew towards over-delivering care, often with Tiny to no plus to patients. Nor should it be approach as a warn about of value-based care.
But with all of the optimistic fanfare (a little 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 reach 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 harsh practices to govern costs are pursued through the lens of valid 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 want to look in do something for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we say you will to erode the most exaggerated asset we have in the American healthcare system: the trust of the people we serve.
