Losing (and Winning) at Value-Based Care.

First introduced in the mid 2000’s, value-based care was brought to the forefront of medical practice with the 2015 passage of MACRA1. Designed to treat the entire patient, both in illness and health, and reward improved health, value-based care was the antidote to a fee-for-service (FFS), solely treatment- and diagnostic-based approach to the practice of medicine. In theory, it was exactly what both doctors and patients needed to create a culture of improved health and reduce the healthcare system burden of disease. So why, then, has it failed so spectacularly thus far?

While it’s nearly impossible to attribute just one, or even a handful of causes to the lack of traction or success for value-based care, it is possible to assess influence and recommend focused avenues for positive change. Here are a few key areas where changes could have a profound impact and lead to greater success for value-based care.

TIME

Time is a multi-faceted component in medicine. There is the time spent with a patient, time spent on a patient, and time allowed for effectual change to manifest; and they’re all currently being mismanaged. Reports on physician burnout note that less time spent on clinical activities (e.g. face time with patients), and more time on clinical tasks away from patients (e.g. billing and EHR tasks) are leading causes of physician burnout, mutual physician and patient dissatisfaction, poorer health outcomes, and decreased confidence in the healthcare system3,4,5.

Furthermore, chronic illness is developed over time; so, the belief that it can be reversed in one 15-30-minute appointment per year needs to be eliminated. Achieving “goal” health markers needs to be repositioned as a longitudinal goal instead of an absolute goal. Focus on improvement should be rewarded instead of punished for falling short of singular, rigid benchmarks.

TECHNOLOGY

It is no secret that EHRs and associated “clerical” duties are significant pain points for physicians and can sometimes hurt outcomes more than they help3,4,5; however, an oft overlooked part of the problem concerns the origins of software. Few providers are directly involved in software development and design. Conversely, most software developers and designers have not been taught to think like clinicians. Thus, a fundamental divide exists between those responsible for delivery and use of EHR software systems.

Clinicians and those who represent their interests (managers, system leaders) must take an active role in software development and design, ensuring that clinician intuition, needs, and thought processes are reflected in system workflows. Additionally, increased clinician perspective helps identify potentially beneficial applications of machine learning and AI programming.

RESOURCE UTILIZATION

A final area with considerable impact on the realization of value-based outcomes is resource utilization. First and foremost, providers cannot be expected to achieve these outcomes alone. Instead, healthcare must truly become a team effort, incorporating the use of various clinicians and venues6. Medicare recognizes and encourages this through the application of “general supervision” requirements for most services that increase patient touchpoints and improve monitoring: medication therapy management (MTM), chronic care management (CCM), remote patient monitoring (RPM), and the coming remote therapeutic monitoring (RTM). All these services are grossly underutilized when current utilization rates are compared to eligible populations7.

The effective application of diffuse and continuous contact with patients increases the likelihood of reinforcing health-centric behaviors. It also improves early detection and intervention on potentially problematic conditions and exacerbations and reduces provider burden on outcome expectations.

WINNING AT VALUE-BASED CARE

Value-based care is still young, and entrenched healthcare practices have made its application an uphill battle. But with some changes in perspective, sharing of responsibility, and improved tools, a true “win” in value-based care is not only possible, but truly on the visible horizon.

REFERENCES

1. Southward MW, Cassiello-Robbins C, Zelkowitz R, Rosenthal MZ. Navigating the New Landscape of Value-Based Care: An Example of Increasing Access, Improving Quality, and Reducing Costs Using the Unified Protocol. doi:10.31234/osf.io/rvbzn

2. Lee TH, Elsawy T. The value of value-based care, during a pandemic and beyond. NEJM Catalyst Innovations in Care Delivery. 2020;1(4)

3. Yates SW. Physician Stress and Burnout. The American Journal of Medicine. 2020/02/01/ 2020;133(2):160-164. doi:https://doi.org/10.1016/j.amjmed.2019.08.034

4. Collier R. Electronic health records contributing to physician burnout. Canadian Medical Association Journal. 2017;189(45):E1405-E1406. doi:10.1503/cmaj.109-5522

5. Patel UK, Zhang MH, Patel K, et al. Recommended Strategies for Physician Burnout, a Well-Recognized Escalating Global Crisis Among Neurologists. J Clin Neurol. 2020;16(2):191-201. doi:10.3988/jcn.2020.16.2.191

6. Grimes PE. Physician burnout or joy: Rediscovering the rewards of a life in medicine. Int J Womens Dermatol. 2019;6(1):34-36. Published 2019 Dec 27. doi:10.1016/j.ijwd.2019.12.001

7. American Pharmacists Association. APhA comments on physician fee schedule for 2021 to CMS [open letter].
   https://conhi.asu.edu/sites/default/files/ama citation style tip sheet.pdf. Published October 5, 2020. Accessed December 3, 2021.