By Matt Fisher, Healthcare Attorney
LinkedIn: Matthew Fisher
X: @matt_r_fisher
Host of Healthcare de Jure – #HCdeJure
Value based care has become an evergreen topic in healthcare circles with the accompanying message that value based care will transform healthcare. Is that transformation happening? Is the value based care discussion stagnating or getting stuck on certain concepts? Those are valid questions and ones that require a lot of unpacking as well as willingness to pursue different pathways to value.
One big grain of salt to take with these musings is that these are all based on personal opinion and interpretations of what I can observe in the healthcare industry. I am admittedly not basing these considerations on hard data, but what sifts through my mind after observing a lot of different interactions and reading of articles.
What Has Been Happening
The focus on value based care has accelerated since passage of the Affordable Care Act. Those efforts have focused on lot on advancing use of accountable care organizations (ACOs) and implementing bundled payment models. The basis of an ACO is bringing together various independent players, which usually included physician groups and hospitals, to coordinate care and ostensibly take on upside and downside risk. As time has progressed, it is not clear if those models are being meaningfully adopted or experiencing evolution.
Looking at ACOs first, the model has not apparently resulted in a large number of organizations getting to the point of taking on full risk. One of the original arguments in favor of ACOs was that it would help lay the infrastructure to move away from fee for services and instead focus on high quality, efficient care that would in turn translate to care delivery organizations assuming full risk for patient populations. Instead, participants in many of the various iterations of the model launched by the Centers for Medicare and Medicaid Services (CMS) dabbled by doing upside benefit only and then backing out before transitioning into up and down risk.
Even for those participants that did get into higher degrees of risk, complaints would be voiced about how payment or risk scores were calculated. While disagreements between participants and CMS were inevitable, an inability to reach full consensus on risk scoring and measuring progress of achieving savings is not a recipe for long term success.
Looking at how quality or success is measured, another hindrance is the multitude of measuring factors. It feels as though every value based care model takes its own approach, which adds to the complexity and administrative time. Further, the differing means of measurement translate to increased burdens on clinicians by having to track arguably the same issue in different ways for different programs. That all leads to frustration and questioning of whether the measures actually mean anything. Beyond those problems, lack of uniformity could also hold back the opportunity to scale programs because there is no alignment from one situation to the next.
Turning to bundled payments, arguably that has been a somewhat better model pursued by CMS. From one side, the “better” outcome was driven by making some of the bundled payment programs mandatory, which meant the models could not be avoided (the way to overcome many ACO participants not going to up and down risk). While the participation involved more comprehensive value from that perspective, data did not consistently show that quality kept improving or that true cost savings occurred. Instead, non-mandatory programs would see drop out while the same concerns about the methodology for calculating the bundled payment rate were raised.
What can be taken away from these high level thoughts about key CMS programs? There is a desire to deliver care that is more efficient, higher quality, and coordinated. However, if delivering care in that manner reduces any players share of the reimbursement pie, questions will be raised.
Where Is VBC Going?
The discussion of a few of the CMS models only scratches the surface and doesn’t even delve into what is happening in the commercial market at all. Despite that limited consideration, one issue that remains prevalent is the relatively slow pace of adoption and remaining with feet still firmly planted in the fee for service world.
The limited adoption should force a fair discussion of whether the drive into full risk is a sustainable or achievable goal. Many considerations go into that discourse, including whether care delivery organizations are setup to take on all of that risk, how does it impact the financial viability of some facilities, should insurance be involved, and a whole host of other considerations.
An interesting take that came up recently was to focus on promoting high value and quality organizations by promoting the care delivery received at those facilities. That is an approach to value that also acknowledges the volume consideration. Breaking it down, the concept is that higher value and quality organizations will be promoted to receive more patients, which means being able to deliver more services. There could be some contractual structuring the reward that value, but ultimately it would mean that higher performing organizations grab a larger share of the market. Arguably, that approach reflects other more consumer driven approaches where good performance gains loyalty and returns.
While the rewarding of good delivery is an approach to value, it isn’t certainly not the promise of putting everything at risk and forcing change in that manner. That is potentially a good outcome because just trying to force organizations into a certain model without proper preparation could be harmful across the board.
Regardless of the actual approach, the discussion on value based care is ripe for a reorientation. ACO models are holding on but still draw a lot of comments on structure. Other ideas have not necessarily gone anywhere. All of that means lessons should be learned by crunching through available data and hopefully identifying what is working and more importantly what is not working. Once those insights are learned, then all impacted stakeholders should be convened to advance the parameters for value based care in a consensus driven way. The consensus ideally would be the result of compromise where everyone feels both good and bad about what is happening. If anyone feels only good or bad, then a flaw likely still exists.
Will any of that occur? It’s a good question and one that may not be able to be answered. However, it is clear that some alteration of the path being followed for value based care is needed, or the healthcare industry will likely be in the same place it is currently in for the foreseeable future.
This article was originally published on The Pulse blog and is republished here with permission.