Attend any healthcare conference and you’ll quickly discover that it’s become downright accepted for healthcare leaders to chat about their fixed commitment to “value-based care.”
The aeration 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 moot 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 processing 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 account 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 demean cost of care for a population of patients, while aiming to total outcomes.
But what does this value-based care look 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 than a close professor friend 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 intervention that was contracted when her Medicare Advantage plan.
On one occasion, his mother was discharged from a hospital sooner than he felt she should have been (she was vanguard readmitted). On marginal occasion, she was denied access to a tertiary cancer center, where he believed she should have afterward for a second opinion. And on a third occasion, she was denied right of entry 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 support but think that he (and others) are someway failing to link up the dots in the middle of the promise of value-based care and its real-world implications. Which got me thinking that it perhaps might be cooperative for whatever 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 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 endeavor that partners contiguously with many value-based groups.
Tracking Hospital
While pharmaceutical costs gain a lot of attention, the single most costly line item for many groups lively in the “value-based care” space is executive 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 gain entrance to rates (admissions/1,000 patients) on a daily basis. The subjugate the numbers the better.
The overall intend is to try to avoid hospitalizations by to the side of managing patients in outpatient clinics and sometimes directly admitting patients to skilled nursing facilities, whose costs are significantly degrade than those of hospitals. Intensive outpatient executive often includes enhanced right of entry to primary and urgent care and better organization of chronic disease—all with the aspire 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 harsh bed day presidency often translates into demean hospitalization rates and condensed hospitalizations, but it can sometimes leave patients and families feeling rude and uncared for in their most vulnerable moments. Patients who expect (and sometimes need) long hospital stays might be amazed when they’re discharged immediately to their homes with house care facilities or to skilled-nursing facilities in lieu of an other few nights in the hospital.
In addition, many value-based care groups prioritize numbing care and proactively transition patients to hospice—in part, because it’s often the right event to do, and in portion because patients taking into account end-stage conditions often gain admitted to the hospital and utilize countless expensive (and futile) hospital bed days. Patients in these groups sometimes quality that their doctors are hurrying them alongside the pathway of numbing care and hospice prematurely, when they themselves have a want to keep fighting their illnesses.
Specialist care
Like hospitalizations, specialist care—with anything of its allied tests and methodical 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 pro in the hands of confident generalist primary care physicians who accept more answerability for patients and their outcomes than those who act out in received primary care models. These generalist doctors only forward to specialists in imitation of they craving an enlightened opinion or the tolerant requires a procedure that they aren’t nimble 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 be anxious and have destitute outcomes thus of those delays. Because of the focus on gatekeeping, patients often find themselves frustrated 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 unaided ones complaining. Almost all practicing doctor will tell you stories more or less how much behave it sometimes takes to obtain cheer for referrals that are absolutely essential and just make common sense.
Relationships
Many value-based care groups contract taking into account narrow networks of specialists and medical centers. Members of these networks are usually selected because they have contact with the primary care groups and are sometimes employed members of their group (as with Kaiser Permanente).
Increasingly, groups are using network analytic tools later than Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and careful about their use of systematic tests and procedures.
The utility of these kinds of networks are manifold. Groups deliberately curate specialists who communicate and coordinate effectively in imitation of 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 photograph album systems that can more seamlessly help care coordination and the flow of long-suffering information across clinical sites.
The downside is that some value-based networks are for that reason focused on cost direction that they tend to contract later than specialists and hospitals based more on cost than on quality. Many “value-based” groups seem to steer positive of contracting taking into account the most reputable (and sometimes future quality) hospitals and their united physician groups because they are expensive. Patients used to going to whatever facility they with for care are often surprised at how narrow the offerings are within their networks, especially in the unfortunate circumstances subsequently patients tend to take aim 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 additional 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 addition the put-on of physicians in the publicize of nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The auxiliary of these clinical practitioners can improve access to care and also complement outcomes subsequent to they appear in as ration of a team to more effectively coordinate the care of patients and direct their chronic conditions. The best value-based care groups have clear and dynamic rubrics for how whatever members of the clinical teams put-on together to encourage patients.
On the other hand, patients who desire to see physicians—or, sometimes, need to look physicians—often gain 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 everything types interchangeably without paying near attention to differences in skills and knowledge across clinician types—or articulating a certain 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 hire for the care of patients.
In practice, this means they tend to favor drugs in the same way as 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 humiliate 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 point of ignoring far along cost drugs that can meaningfully put to rest patients’ suffering. The thesame can be said about ahead of its time diagnostics and newer procedural interventions.
Value-based care groups can quickly find themselves at odds in the same way as their patients next their recommendations and treatment plans contradict what patients themselves learn affect their own research on the best and most futuristic course of operate 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 aggravating to dream at the root cause of why someone is absorbing healthcare services, sometimes focus upon non-traditional, non-medical interventions that complement outcomes even though lowering the sum cost of care for patients.
When I was at CareMore, our care direction team with procured a refrigerator for a uncomplaining who needed it to deposit 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 description of buying an Apple iPod to soothe a accommodating whose shakeup led him to the emergency room higher than 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 trying 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 house social determinants of health have unproductive to rouse any meaningful healthcare atmosphere or cost gain to the programs.
What’s more, while many value-based care organizations (including two I have led) provide right of entry to gym benefits, transportation, food, and new interventions intended to complement key drivers of health, the published literature does not maintain the notion that these advance have a meaningful effect on cost or the vibes of outcomes—though the effect on 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 cartoon trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically accustom yourself payments for patients based upon the sharpness of their illnesses. As a result, many value-based care organizations spend significant activity documenting the depth 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 push away annual physicals. The want of these visits is not at all determined to patients. But for the medical groups, these “welcome visits” identify unmet medical needs and motivate 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 completely divorced from a patient’s care and support exclusively to maximize the payments groups get from payers. These types of visits are often regarded as non-value further 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 even if improving setting necessarily means creating some abrasion for some patients some of the time. And past 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 group may sometimes go adjoining the care that the long-suffering feels he or she needs. As my late economics teacher, Martin S. Feldstein, often said, “There’s no such situation as a free lunch.”
When a doctor denies a uncomplaining a exam or new 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 with 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 beast made to optimize care or to guard quarterly earnings?
Said substitute way, is the close term law focused upon the cost allowance of the famed value equation? Or the character portion?
It’s not always easy to know.
This set of questions and interpretation should not be gate as a explanation of the costly, traditional fee-for-service system, which has its own skew towards over-delivering care, often with little to no improvement to patients. Nor should it be retrieve as a warn about of value-based care.
But with everything of the optimistic fanfare (a small portion of which I, too, am guilty of generating) must with come a dose of realism. Value-based care can indeed be an solution to some of what ails American healthcare, but at its introduction 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 control costs are pursued through the lens of legal 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 want to look in undertaking for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we endure to erode the most unnatural asset we have in the American healthcare system: the trust of the people we serve.
