Attend any healthcare conference and you’ll quickly discover that it’s become downright accepted for healthcare leaders to talk about their fixed commitment to “value-based care.”
The ventilation 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 executive 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 easy enough—managing to a belittle cost of care for a population of patients, while aiming to affix outcomes.
But what does this value-based care look like in practice in the real-world of tolerant 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 close professor friend who has long been a fan of value-based care. On our call, he expressed dismay at his mother’s care in a value-based medical intervention that was contracted later her Medicare Advantage plan.
On one occasion, his mom was discharged from a hospital sooner than he felt she should have been (she was forward-thinking readmitted). On marginal occasion, she was denied entry to a tertiary cancer center, where he believed she should have with 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 buddy decried his mother’s care experience, I couldn’t help but think that he (and others) are somehow failing to link up the dots amongst the concurrence of value-based care and its real-world implications. Which got me thinking that it perhaps might be accepting for all of us to see closely at what value-based care means—good and bad—for patients receiving care governed by its principles.
These interpretation arise from my become old 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 mean that partners nearby with many value-based groups.
Tracking Hospital
While pharmaceutical costs get a lot of attention, the single most expensive line item for many groups dynamic in the “value-based care” space is meting out 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 hours of daylight in the hospital, leaders of many value-based care organizations are in the compulsion of tracking hospital bed days (bed days/1,000 patients) and door rates (admissions/1,000 patients) on a daily basis. The subjugate the numbers the better.
The overall try is to attempt to avoid hospitalizations by to the side of managing patients in outpatient clinics and sometimes directly admitting patients to talented nursing facilities, whose costs are significantly demean than those of hospitals. Intensive outpatient doling out often includes enhanced admission to primary and urgent care and better dealing out of chronic disease—all as soon as the goal of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups also make home calls to patients. The more technologically-enabled ones remotely monitor patients at particularly tall risk of hospitalization.
Such coarse bed day processing often translates into degrade 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 amazed when they’re discharged hastily to their homes with house care facilities or to skilled-nursing services in lieu of an extra few nights in the hospital.
In addition, many value-based care groups prioritize painkiller care and proactively transition patients to hospice—in part, because it’s often the right concern to do, and in part because patients taking into consideration 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 down the passage of pain-relieving care and hospice prematurely, when they themselves have a want to save fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with whatever of its allied tests and questioning procedures—can be expensive. In fee-for-service environments, primary care physicians often talk 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 liability for patients and their outcomes than those who pretense in received primary care models. These generalist doctors only focus on to specialists subsequent to they need an militant opinion or the long-suffering requires a procedure that they aren’t competent to feat themselves.
Of course, there can be a downside. Patients who belong in the hands of specialists are sometimes delayed getting there—and can dwell on and have destitute outcomes hence 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 logical tests. And patients aren’t the on your own ones complaining. Almost all practicing doctor will tell you stories nearly how much fake it sometimes takes to obtain approval for referrals that are absolutely indispensable and just make common sense.
Relationships
Many value-based care groups contract as soon as narrow networks of specialists and medical centers. Members of these networks are usually chosen because they have contact with the primary care groups and are sometimes employed members of their group (as afterward Kaiser Permanente).
Increasingly, groups are using network critical tools like Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and cautious about their use of questioning tests and procedures.
The support of these kinds of networks are manifold. Groups with intent curate specialists who communicate and coordinate effectively later 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 LP systems that can more seamlessly benefits care coordination and the flow of tolerant information across clinical sites.
The downside is that some value-based networks are for that reason focused upon cost giving out that they tend to contract next specialists and hospitals based more upon cost than on quality. Many “value-based” groups seem to steer distinct of contracting when the most reputable (and sometimes well along quality) hospitals and their united physician groups because they are expensive. Patients used to going to whatever facility they behind for care are often amazed at how narrow the offerings are within their networks, especially in the unfortunate circumstances next patients tend to purpose out intensely 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 condense costs, many value-based care groups often introduce further 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 take steps of physicians behind nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The complement of these clinical practitioners can include access to care and also add together outcomes considering they statute as share of a team to more effectively coordinate the care of patients and rule their chronic conditions. The best value-based care groups have distinct and functioning rubrics for how anything members of the clinical teams conduct yourself together to utility patients.
On the further hand, patients who want to see physicians—or, sometimes, need to look physicians—often get frustrated that access to generalist physicians (and specialists) might be limited by non-physician gatekeepers. What’s more, the worst value-based care groups use professionals of whatever 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 progress of the formularies they hire for the care of patients.
In practice, this means they tend to favor drugs past 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 belittle 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 supplementary drugs on formularies and are sometimes price-focused to the reduction of ignoring cutting edge cost drugs that can meaningfully calm patients’ suffering. The same can be said about protester diagnostics and newer procedural interventions.
Value-based care groups can speedily find themselves at odds once their patients considering their recommendations and treatment plans contradict what patients themselves learn proceed their own research on the best and most advanced course of produce a result 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 a pain to drive at the root cause of why someone is absorbing healthcare services, sometimes focus on non-traditional, non-medical interventions that add together outcomes even if lowering the total cost of care for patients.
When I was at CareMore, our care giving out team subsequently procured a refrigerator for a patient who needed it to deposit his insulin, recognizing that without the refrigerator, the patient would likely house in the hospital with high blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the balance of buying an Apple iPod to soothe a tolerant whose campaigning led him to the emergency room exceeding 100 era 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 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 unsuccessful to work up any meaningful healthcare tone or cost plus 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 additional interventions intended to count up key drivers of health, the published literature does not support the notion that these relief 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 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 vivaciousness trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically accustom yourself payments for patients based on the sharpness of their illnesses. As a result, many value-based care organizations spend significant spirit documenting the depth 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 make unfriendly annual physicals. The objective of these visits is not at all positive 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 whatever of the medical conditions patients experience.
Yet as few would dispute, at their worst, these visits are sometimes no question divorced from a patient’s care and encouragement exclusively to maximize the payments groups receive from payers. These types of visits are often regarded as non-value other overhead.
lowering the total cost
As I explained to my friend who was concerned approximately his mother’s care, the untold tab of value-based care is that lowering the sum cost of care while improving atmosphere necessarily means creating some abrasion for some patients some of the time. And later this abrasion will inevitably come the feeling of a battle of interest, real or imagined. The financial bottom-line of the doctor and his medical action may sometimes go against the care that the tolerant feels he or she needs. As my late economics teacher, Martin S. Feldstein, often said, “There’s no such business as a clear lunch.”
When a doctor denies a compliant a test or supplementary 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 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 other pharmaceutical brute made to optimize care or to protect quarterly earnings?
Said unorthodox way, is the near term put-on focused upon the cost allocation of the famed value equation? Or the setting portion?
It’s not always simple to know.
This set of questions and observations should not be log on 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 plus to patients. Nor should it be right to use as a reprimand of value-based care.
But with everything of the optimistic fanfare (a small portion of which I, too, am guilty of generating) must after that come a dose of realism. Value-based care can indeed be an answer to some of what ails American healthcare, but at its initiation 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 unfriendly practices to rule costs are pursued through the lens of true benefit to the patient, not the financial interests of the group. The undertakings to which we subject patients must be guided by the “radical common sense” that every one of us would desire to see in appear in for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we put up with to erode the most pretentious asset we have in the American healthcare system: the trust of the people we serve.
