Attend any healthcare conference and you’ll quickly discover that it’s become downright well-liked for healthcare leaders to chat about their unwavering commitment to “value-based care.”
The drying 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 school 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 management 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 on the value bandwagon.
The underlying principle of “value-based care” is simple enough—managing to a lower cost of care for a population of patients, while aiming to intensify 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 as soon as a near professor friend who has long been a lover of value-based care. On our call, he expressed dismay at his mother’s care in a value-based medical organization that was contracted in the tune of her Medicare Advantage plan.
On one occasion, his mother was discharged from a hospital sooner than he felt she should have been (she was well ahead readmitted). On substitute occasion, she was denied access to a tertiary cancer center, where he believed she should have similar to for a second opinion. And upon a third occasion, she was denied right of entry 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 stirring to but think that he (and others) are someway failing to affix the dots amongst the contract of value-based care and its real-world implications. Which got me thinking that it perhaps might be obliging 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 observations 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 target that partners closely with many value-based groups.
Tracking Hospital
While pharmaceutical costs gain a lot of attention, the single most expensive line item for many groups keen in the “value-based care” space is handing out 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 craving of tracking hospital bed days (bed days/1,000 patients) and right to use rates (admissions/1,000 patients) on a daily basis. The belittle the numbers the better.
The overall strive for is to attempt to avoid hospitalizations by to the side of managing patients in outpatient clinics and sometimes directly admitting patients to proficient nursing facilities, whose costs are significantly subjugate than those of hospitals. Intensive outpatient meting out often includes enhanced entry to primary and urgent care and better paperwork of chronic disease—all subsequently the mean of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups furthermore make house calls to patients. The more technologically-enabled ones remotely monitor patients at particularly high risk of hospitalization.
Such sharp bed day management often translates into subjugate hospitalization rates and shortened hospitalizations, but it can sometimes leave patients and families feeling hasty and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be surprised when they’re discharged sharply to their homes with home 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 painkilling care and proactively transition patients to hospice—in part, because it’s often the right thing to do, and in allocation because patients subsequently end-stage conditions often gain admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes feel that their doctors are speeding up them down the path of numbing care and hospice prematurely, when they themselves have a desire to keep fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with anything of its united tests and reasoned procedures—can be expensive. In fee-for-service environments, primary care physicians often adopt 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 answerability for patients and their outcomes than those who action in conventional primary care models. These generalist doctors only take up to specialists like they compulsion an advocate opinion or the long-suffering requires a procedure that they aren’t clever to law 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 destitute outcomes correspondingly of those delays. Because of the focus upon gatekeeping, patients often find themselves exasperated by utilization management—the administrative process through which health plans and medical groups review referrals to specialists and orders for questioning tests. And patients aren’t the lonesome ones complaining. Almost all practicing doctor will say you stories just about how much perform it sometimes takes to obtain commendation for referrals that are absolutely essential and just make common sense.
Relationships
Many value-based care groups contract taking into consideration narrow networks of specialists and medical centers. Members of these networks are usually agreed because they have interaction with the primary care groups and are sometimes employed members of their group (as with Kaiser Permanente).
Increasingly, groups are using network analytic tools gone Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and cautious about their use of logical tests and procedures.
The assistance of these kinds of networks are manifold. Groups carefully curate specialists who communicate and coordinate effectively past 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 see for….?”). And these specialists often operate upon common electronic health wedding album systems that can more seamlessly advance care coordination and the flow of accommodating information across clinical sites.
The downside is that some value-based networks are hence focused upon cost direction that they tend to contract next specialists and hospitals based more on cost than on quality. Many “value-based” groups seem to steer positive of contracting subsequent to the most reputable (and sometimes superior quality) hospitals and their joined physician groups because they are expensive. Patients used to going to anything facility they later than for care are often surprised at how narrow the offerings are within their networks, especially in the unfortunate circumstances subsequently patients tend to direct out highly 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 abbreviate 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 top of the license.” In practice, it means groups accessory the take effect of physicians taking into consideration nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The addition of these clinical practitioners can improve access to care and also enlarge outcomes later than they enactment as part of a team to more effectively coordinate the care of patients and manage their chronic conditions. The best value-based care groups have certain and enthusiastic rubrics for how everything members of the clinical teams take action together to advance patients.
On the extra hand, patients who desire to look physicians—or, sometimes, need to see physicians—often gain 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 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 progress of the formularies they employ 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 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 new drugs on formularies and are sometimes price-focused to the reduction of ignoring far along cost drugs that can meaningfully relieve patients’ suffering. The similar can be said about modern diagnostics and newer procedural interventions.
Value-based care groups can speedily find themselves at odds in the same way as their patients once their recommendations and treatment plans contradict what patients themselves learn produce an effect their own research upon the best and most objector course of 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 goal at the root cause of why someone is absorbing healthcare services, sometimes focus upon non-traditional, non-medical interventions that increase outcomes even if lowering the sum cost of care for patients.
When I was at CareMore, our care handing out team afterward procured a refrigerator for a patient who needed it to buildup his insulin, recognizing that without the refrigerator, the long-suffering would likely home in the hospital with tall blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the balance of buying an Apple iPod to soothe a uncomplaining whose tension led him to the emergency room on culmination of 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 exasperating 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 quarters social determinants of health have unsuccessful to shake up any meaningful healthcare air or cost improvement 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 meant to swell key drivers of health, the published literature does not Keep the notion that these minister to have a meaningful effect upon cost or the atmosphere of outcomes—though the effect on select individual patients is incontrovertible.
Revenue Focused?
While in its purest form, value-based healthcare is more or less 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 sparkle trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically get used to payments for patients based on the intensity of their illnesses. As a result, many value-based care organizations spend significant activity documenting the intensity of illness—time some patients may air takes away from actually caring for them. For example, some medical groups hire home-based “welcome visits” from third-party vendors push away annual physicals. The want of these visits is not at all positive to patients. But for the medical groups, these “welcome visits” identify unmet medical needs and start 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 categorically divorced from a patient’s care and bolster exclusively to maximize the payments groups get from payers. These types of visits are often regarded as non-value extra overhead.
lowering the total cost
As I explained to my friend who was concerned just about his mother’s care, the untold credit of value-based care is that lowering the total cost of care even though improving feel necessarily means creating some abrasion for some patients some of the time. And afterward this abrasion will inevitably come the feeling of a combat of interest, real or imagined. The financial bottom-line of the doctor and his medical organization 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 concern as a clear lunch.”
When a doctor denies a patient a test or further drug or referral to a specialist, is it because we are really optimizing the care of the patient?
Or is it because we are optimizing the economics of the value-based group?
In an era afterward 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 being made to optimize care or to guard quarterly earnings?
Said marginal way, is the close term take effect focused upon the cost allocation of the famed value equation? Or the quality portion?
It’s not always simple to know.
This set of questions and explanation should not be log on 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 gain to patients. Nor should it be edit as a reprove of value-based care.
But with all 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 instigation there must be something somewhat increasingly quaint and elusive:
An ethical underpinning to always do 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 manage costs are pursued through the lens of valid 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 look in put-on for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we acknowledge to erode the most precious asset we have in the American healthcare system: the trust of the people we serve.
