The major roadblocks holding back value-based care

Steven Loeb · March 13, 2024 · Short URL:

One of the biggest issues is 75% associate value-based care with cheap, low quality service

Even as value-based care continues to grow, there are a number of challenges that standing in the way off full adoption. One of those is how value-based care is defined, as it can't be fully implemented until everyone is on the same page about what it actually means. Other problems include doctors having different contracts with different payers, as well as unfounded ideas that value-based care means lower quality care.

"64% of Americans support value-based care over fee for service, 59% said they supported the term value-based care, but 75% associated the term with cheap, low quality services. I'm not sure that the panelists think that that's what value-based care means," Bambi Francisco (Founder and CEO, Vator) said last week at "Value-based care — Are we there yet," the latest invent health salon in partnership with MIT Club of Northern California.

"It's interesting to see that there's this disconnect between what patients think and what the providers think and payers think."

The panel was co-moderated by Dr. Archana Dubey (Chief Medical Officer, United Healthcare), and featuring Afsana Akhter (Digital Health CEO); Dr. Edward M. Yu (Chief Medical Officer, Population Health, Sutter Health); Dr. Pamela Laesch (SVP, Clinical Services Hill Physicians Medical Group); Khanh Gia Nguyen (CEO, Cozeva).

For Dubey, one of the issues is that the patient is not involved in the decision making about their care.  spoke first from the perspective of somebody who has seen many different side of the ecosystem: she' been a practitioner, an employer, a strategist, and now works at a health plan.

"Most of the value-based care definitions and contracts and relationships are mostly defined between the provider and the health plans. Generally, the member or the patient is not part of that deal and that is the disconnect. That is a gap that we need to address," she said. 

Laesch agreed, noting that Hill Physicians is really focused on patient outcomes and, ideally, they want to be able to detect diseases early. That means more actively involving the patient in their own care by educating them. 

"We want to get patients into health education, maybe into continuous glucose monitoring: you may be diagnosed with new diabetes, so how do we get those patients into these programs when they're not within the four walls of the physician's office or a telehealth visit? Because people live most of their lives outside of that situation," she said. 

For Nguyen, part of Cozeva's mission to help make things easier for all stakeholders, including physicians, who may not have the bandwidth to fully understand what they need to do for each individual value-based contract, which came come with their own individual metrics. 

"When we say we enable and we help operationalize and make value-based care easy for all stakeholders, we are also thinking about it from the lens of the practicing physician. Think of that physician who's contracted with like 30 different payers, and payers can have very different meanings: it can be a provider group or a health system or a health plan for direct contracting. As a physician, it is overwhelming to understand, ‘for this contract, what do I have to pay attention to? And for this population, what do I have to pay attention to?' We want to make it simple and easy for the provider to just do the right thing."

Nguyen also brought up transparency and data, noting that, in order for value-based care to happen, you have to have the data, and you have to have the ability to use the data in the right way, which is what Cozeva does on behalf of all of its users.

"We also have the ability to create transparency across provider, provide group, health plan, all the people that are touching the same patient, all the people that are quote, unquote, having slices of care for that same patient, now get to see that information and the real time reporting of the quality of care delivered for that patient," she said. 

Yu brought up the statistics that Francisco opened with about people viewing value-based care as the cheapest care, which he called "a common misconception." And so, part of Sutter's mission when it comes to value-based care is to reduce avoidable costs, when they can be.

"Not all costs are avoidable in healthcare: if you have a patient that ends up having leukemia, and needs a bone marrow transplant to get the outcome, you spend the money and spend the resources to get that. And it's not always the cheapest care. Where it matters, and you may have heard this a lot about healthcare, the way we're set up, we’re siloed, things are not integrated, there is tremendous waste in the system. Our job is to take out the waste, take out the inefficiencies," he said.

"Part of how you make that paradigm is understanding where patients are. Getting back to the health equity piece, each patient is different. Not all patients want surgery. How do you understand where they are, where they want to be, and match them where they are with different clinical pathways to generate the outcomes? So, it's about improving health and reducing avoidable costs. That, to me, is what the mission of value-based care should be."

Akhter also brought up cost and quality and how they are "very counterintuitive" in healthcare because in every other aspect of our lives higher quality is associated with higher price or higher price is associated with higher quality, except in healthcare.

"In healthcare, it can really be the inverse and that's what consumers often don't realize. Why is that? Because when a surgery is done, or a test is performed, if it's done well, it doesn't lead to complications, it doesn't cause readmissions, it doesn't lead to duplicated effort and tests. And so, the cost can actually be lower when a service is higher quality and that's something we as consumers need to keep in mind," she said.

"When we select providers, or even a health plan, we need to look for quality, not just price."

She also brought up what Dubey had mentioned: that the patient, or end consumer, is being left out, in part because they don';t understand the language being used.

"The words that are used to describe quality in Healthcare are also not common terms. How many people have heard of HEDIS? Or Stars? That's how quality is described in healthcare. It's not our dinner table language. So, it's important for the healthcare system to present quality in a consumer digestible way," said Akhter.

"It's also important for us, as consumers, to really ask the question: I'm picking a provider, how do I know who's better quality? Who's going to give me the best care? And not just judging based on, ‘Oh, this one's more expensive so it's, it should be better.’ Not necessarily."

See the video of the panel below: 

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