Attend any healthcare conference and you’ll quickly discover that it’s become downright accepted for healthcare leaders to chat about their inflexible 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 assistant professor 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 past 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 simple enough—managing to a belittle cost of care for a population of patients, while aiming to insert outcomes.
But what does this value-based care see like in practice in the real-world of compliant care (beyond the industry conference jargon and academic expositions on the subject)?
I got the idea for this column after a recent call afterward 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 organization that was contracted once her Medicare Advantage plan.
On one occasion, his mommy was discharged from a hospital sooner than he felt she should have been (she was innovative readmitted). On marginal occasion, she was denied admission to a tertiary cancer center, where he believed she should have past for a second opinion. And upon a third occasion, she was denied admission 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 put happening to but think that he (and others) are somehow failing to connect the dots amongst the concurrence 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 look closely at what value-based care means—good and bad—for patients receiving care governed by its principles.
These notes arise from my mature 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 plan that partners nearby with many value-based groups.
Tracking Hospital
While pharmaceutical costs get a lot of attention, the single most costly line item for many groups functional in the “value-based care” space is management 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 dependence of tracking hospital bed days (bed days/1,000 patients) and open rates (admissions/1,000 patients) on a daily basis. The demean the numbers the better.
The overall point toward is to try to avoid hospitalizations by alongside managing patients in outpatient clinics and sometimes directly admitting patients to talented nursing facilities, whose costs are significantly lower than those of hospitals. Intensive outpatient dealing out often includes enhanced admission to primary and urgent care and better supervision of chronic disease—all considering the intention 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 tall risk of hospitalization.
Such coarse bed day supervision often translates into subjugate hospitalization rates and condensed hospitalizations, but it can sometimes leave patients and families feeling immediate and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be amazed when they’re discharged suddenly to their homes with house care services or to skilled-nursing facilities in lieu of an new 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 portion because patients following end-stage conditions often get admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes vibes that their doctors are hurrying them all along the lane of numbing care and hospice prematurely, when they themselves have a want to keep fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with whatever of its associated tests and investigative procedures—can be expensive. In fee-for-service environments, primary care physicians often take in hand 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 answerability for patients and their outcomes than those who produce an effect in normal primary care models. These generalist doctors only deliver to specialists subsequently they craving an advanced opinion or the patient requires a procedure that they aren’t nimble to bill themselves.
Of course, there can be a downside. Patients who belong in the hands of specialists are sometimes delayed getting there—and can vacillate and have destitute outcomes hence of those delays. Because of the focus on 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 investigative tests. And patients aren’t the deserted ones complaining. Almost all practicing doctor will say you stories practically how much proceed it sometimes takes to obtain applaud for referrals that are absolutely valuable and just make common sense.
Relationships
Many value-based care groups contract afterward narrow networks of specialists and medical centers. Members of these networks are usually fixed because they have dealings with the primary care groups and are sometimes employed members of their group (as later Kaiser Permanente).
Increasingly, groups are using network diagnostic tools taking into account Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and careful about their use of questioning tests and procedures.
The encouragement of these kinds of networks are manifold. Groups purposefully 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 upon common electronic health photograph album systems that can more seamlessly utility care coordination and the flow of tolerant information across clinical sites.
The downside is that some value-based networks are thus focused on cost running that they tend to contract later than specialists and hospitals based more upon cost than on quality. Many “value-based” groups seem to steer Definite of contracting later the most reputable (and sometimes complex quality) hospitals and their allied physician groups because they are expensive. Patients used to going to anything facility they afterward for care are often amazed at how narrow the offerings are within their networks, especially in the unfortunate circumstances subsequently patients tend to intention out intensely 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 abbreviate 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 summit of the license.” In practice, it means groups complement the discharge duty of physicians similar to nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The auxiliary of these clinical practitioners can intensify access to care and also total outcomes gone they exploit as portion of a team to more effectively coordinate the care of patients and manage their chronic conditions. The best value-based care groups have Definite and full of zip rubrics for how everything members of the clinical teams comport yourself together to utility patients.
On the extra hand, patients who desire to see physicians—or, sometimes, need to look physicians—often get frustrated that right of 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 all types interchangeably without paying close 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 expand of the formularies they hire for the care of patients.
In practice, this means they tend to favor drugs afterward 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 degrade 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 new drugs upon formularies and are sometimes price-focused to the narrowing of ignoring highly developed cost drugs that can meaningfully put to rest patients’ suffering. The same can be said about advanced diagnostics and newer procedural interventions.
Value-based care groups can speedily find themselves at odds subsequently their patients in the circulate of their recommendations and treatment plans contradict what patients themselves learn play their own research on the best and most objector course of enactment 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 hope at the root cause of why someone is absorbing healthcare services, sometimes focus upon non-traditional, non-medical interventions that add together outcomes while lowering the total cost of care for patients.
When I was at CareMore, our care organization team afterward procured a refrigerator for a patient who needed it to hoard his insulin, recognizing that without the refrigerator, the long-suffering would likely estate in the hospital with high blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the credit of buying an Apple iPod to soothe a long-suffering whose shakeup 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 irritating 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 quarters social determinants of health have fruitless to disturb 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 access to gym benefits, transportation, food, and new interventions expected to combine key drivers of health, the published literature does not maintain the notion that these support have a meaningful effect upon 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 very nearly lowering the total 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 severity of their illnesses. As a result, many value-based care organizations spend significant cartoon documenting the extremity of illness—time some patients may setting takes away from actually caring for them. For example, some medical groups hire home-based “welcome visits” from third-party vendors turn away from annual physicals. The objective of these visits is not at all certain 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 everything of the medical conditions patients experience.
Yet as few would dispute, at their worst, these visits are sometimes totally divorced from a patient’s care and assistance exclusively to maximize the payments groups receive from payers. These types of visits are often regarded as non-value added overhead.
lowering the total cost
As I explained to my friend who was concerned about his mother’s care, the untold bank account of value-based care is that lowering the sum cost of care while improving environment necessarily means creating some abrasion for some patients some of the time. And like 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 work may sometimes go adjoining 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 clear lunch.”
When a doctor denies a accommodating a test or further 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 considering 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 mammal made to optimize care or to protect quarterly earnings?
Said complementary way, is the near term bill focused on the cost allowance 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 log on as a defense 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 admission as a scold of value-based care.
But with everything of the optimistic fanfare (a little portion of which I, too, am guilty of generating) must along with come a dose of realism. Value-based care can indeed be an answer 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 complete 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 direct costs are pursued through the lens of true 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 desire to see in play a part for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we take on to erode the most precious asset we have in the American healthcare system: the trust of the people we serve.
