Attend any healthcare conference and you’ll quickly discover that it’s become downright trendy for healthcare leaders to chat about their stubborn commitment to “value-based care.”
The exposure 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 instructor 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 paperwork 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 subsequently 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 humiliate cost of care for a population of patients, while aiming to intensify outcomes.
But what does this value-based care see like in practice in the real-world of long-suffering care (beyond the industry conference jargon and academic expositions upon the subject)?
I got the idea for this column after a recent call gone a close professor friend who has long been a devotee of value-based care. On our call, he expressed dismay at his mother’s care in a value-based medical outfit that was contracted similar to her Medicare Advantage plan.
On one occasion, his mom was discharged from a hospital sooner than he felt she should have been (she was vanguard 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 entrance 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 put in the works to but think that he (and others) are somehow failing to connect the dots in the company of the bargain of value-based care and its real-world implications. Which got me thinking that it perhaps might be compliant for all of us to look closely at what value-based care means—good and bad—for patients receiving care governed by its principles.
These interpretation arise from my time 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 seek that partners closely with many value-based groups.
Tracking Hospital
While pharmaceutical costs get a lot of attention, the single most costly line item for many groups full of life in the “value-based care” space is executive of acute hospital bed days. A day 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 infatuation of tracking hospital bed days (bed days/1,000 patients) and right of entry rates (admissions/1,000 patients) on a daily basis. The belittle the numbers the better.
The overall object is to attempt to avoid hospitalizations by nearby managing patients in outpatient clinics and sometimes directly admitting patients to competent nursing facilities, whose costs are significantly degrade than those of hospitals. Intensive outpatient government often includes enhanced entrance to primary and urgent care and better management of chronic disease—all subsequent to the want of reducing emergency room visits and subsequent hospitalizations. Many value-based care groups then make home calls to patients. The more technologically-enabled ones remotely monitor patients at particularly tall risk of hospitalization.
Such severe bed day direction often translates into belittle hospitalization rates and reduced 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 gruffly 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 situation to do, and in ration because patients as soon as 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 hurrying them down the passageway of palliative 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 direct 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 benefit in the hands of confident generalist primary care physicians who accept more answerability for patients and their outcomes than those who statute in established primary care models. These generalist doctors only take up to specialists in the same way as they habit an protester opinion or the tolerant requires a procedure that they aren’t skilled 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 vacillate and have poor outcomes correspondingly of those delays. Because of the focus upon gatekeeping, patients often find themselves infuriated by utilization management—the administrative process through which health plans and medical groups review referrals to specialists and orders for diagnostic tests. And patients aren’t the lonely ones complaining. Almost every practicing doctor will tell you stories about how much ham it up it sometimes takes to obtain commendation for referrals that are absolutely vital and just make common sense.
Relationships
Many value-based care groups contract when narrow networks of specialists and medical centers. Members of these networks are usually prearranged because they have contact with the primary care groups and are sometimes employed members of their group (as taking into account Kaiser Permanente).
Increasingly, groups are using network questioning tools subsequent to Cotivity’s RowdMap and Embold Health to identify so-called “high value physicians” who are thoughtful and careful about their use of investigative tests and procedures.
The help of these kinds of networks are manifold. Groups purposefully 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 baby book systems that can more seamlessly advance care coordination and the flow of tolerant information across clinical sites.
The downside is that some value-based networks are therefore focused on cost meting out that they tend to contract subsequently specialists and hospitals based more upon cost than upon quality. Many “value-based” groups seem to steer determined of contracting subsequently the most reputable (and sometimes progressive quality) hospitals and their allied physician groups because they are expensive. Patients used to going to whatever facility they gone for care are often amazed at how narrow the offerings are within their networks, especially in the unfortunate circumstances bearing in mind patients tend to take aim out deeply 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 cut 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 be active of physicians behind nurse practitioners, pharmacists, physician assistants, registered nurses, medical assistants, and community health workers.
The accessory of these clinical practitioners can total access to care and also complement outcomes afterward they statute as portion of a team to more effectively coordinate the care of patients and govern their chronic conditions. The best value-based care groups have Definite and vigorous rubrics for how all members of the clinical teams feint together to benefits patients.
On the extra hand, patients who want to see physicians—or, sometimes, need to see physicians—often get frustrated that entrance to generalist physicians (and specialists) might be limited by non-physician gatekeepers. What’s more, the worst value-based care groups use professionals of anything types interchangeably without paying close attention to differences in skills and knowledge across clinician types—or articulating a determined 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 evolve of the formularies they hire for the care of patients.
In practice, this means they tend to favor drugs following 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 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 further drugs on formularies and are sometimes price-focused to the dwindling of ignoring innovative cost drugs that can meaningfully put to rest patients’ suffering. The same can be said about enlightened diagnostics and newer procedural interventions.
Value-based care groups can quickly find themselves at odds once their patients afterward their recommendations and treatment plans contradict what patients themselves learn play their own research on the best and most futuristic course of do its stuff 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 desire at the root cause of why someone is absorbing healthcare services, sometimes focus upon non-traditional, non-medical interventions that tote up outcomes while lowering the total cost of care for patients.
When I was at CareMore, our care meting out team following procured a refrigerator for a patient who needed it to stock his insulin, recognizing that without the refrigerator, the tolerant would likely estate in the hospital with tall blood sugar. Rushika Fernandopulle, the founder of Iora Health, tells the explanation of buying an Apple iPod to soothe a tolerant whose nervousness led him to the emergency room beyond 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 infuriating 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 address social determinants of health have bungled to disconcert any meaningful healthcare vibes or cost plus 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 meant to count key drivers of health, the published literature does not Keep the notion that these promote have a meaningful effect on cost or the tone of outcomes—though the effect on select individual patients is incontrovertible.
Revenue Focused?
While in its purest form, value-based healthcare is not quite 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 liveliness trying to optimize revenues they earn serving patients.
Payers (including the federal Medicare program) typically adapt payments for patients based on the sharpness of their illnesses. As a result, many value-based care organizations spend significant animatronics documenting the severity of illness—time some patients may quality takes away from actually caring for them. For example, some medical groups hire home-based “welcome visits” from third-party vendors distance annual physicals. The seek of these visits is not at all clear 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 enormously divorced from a patient’s care and serve exclusively to maximize the payments groups receive from payers. These types of visits are often regarded as non-value added overhead.
lowering the sum cost
As I explained to my friend who was concerned nearly his mother’s care, the untold credit of value-based care is that lowering the total cost of care even though improving air necessarily means creating some abrasion for some patients some of the time. And once this abrasion will inevitably come the feeling of a court case of interest, real or imagined. The financial bottom-line of the doctor and his medical group may sometimes go against the care that the accommodating feels he or she needs. As my late economics teacher, Martin S. Feldstein, often said, “There’s no such event as a clear lunch.”
When a doctor denies a long-suffering a test or extra 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 later than 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 further pharmaceutical creature made to optimize care or to guard quarterly earnings?
Said unusual way, is the close term be in focused on the cost portion of the famed value equation? Or the tone portion?
It’s not always simple to know.
This set of questions and clarification should not be entry 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 benefit to patients. Nor should it be entrйe as a warn about of value-based care.
But with all of the optimistic fanfare (a small portion of which I, too, am guilty of generating) must then come a dose of realism. Value-based care can indeed be an answer to some of what ails American healthcare, but at its creation 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 sharp practices to rule costs are pursued through the lens of genuine benefit to the patient, not the financial interests of the group. The comings and goings to which we subject patients must be guided by the “radical common sense” that every one of us would want to see in pretend for ourselves and our parents.
Absent such a culture, value-based care will be the latest strategy we agree to to erode the most pretentious asset we have in the American healthcare system: the trust of the people we serve.
