Be Prepared: Beyond the Alphabet Soup of Value-Based Care

Screen Shot 2014-06-19 at 11.04.40 AMACO, MSSP, BPCI, HIE, CQM, P4P, PCMH, yadda, yadda, yadda … The litany of acronyms describing changing P&D (excuse me, payment and delivery) models can sometimes numb the senses. But it would be unwise to allow the latest healthcare jargon to lull you into an AIC—an acronym-induced coma, for which I believe there is a new ICD-10 code—because the world might look a lot different when you snap out of it.

Little debate exists that the U.S. healthcare system needs to transition from turnstile medicine to value-based care, from a predominantly fee-for-service payment model to one that emphasizes accountability for population health. This, of course, is not a novel concept, so the biggest challenges relate to how we get there. As many skeptics have argued, the same dynamics have existed before – unsustainable healthcare costs and too little value for our money – so the Talmudic question arises: Why is this era different from all other eras?

  1. EHRs have changed the playing field completely
  2. Reporting of comparative performance is now embedded into the delivery system
  3. We understand the centrality of patient engagement
  4. Today’s incentives reward greater accountability and value

There are some fundamental differences compared to, for example, the environment that existed in the 1990s when some experts believed managed care would change the underlying cost structure of the health care system. A majority of providers now have implemented electronic health records (EHRs) and an increasing number are – or soon will be as a result of Stage 2 “Meaningful Use” – able to exchange clinical data across network and vendor boundaries. The expectation that quality measurement will be used for holding providers accountable has taken root and most health care organizations regularly submit standardized performance data to public and private payers, purchasers and independent accrediting bodies. Providers increasingly recognize that their success in population health management relates to their ability to effectively engage with their patients in collaborative relationships.

Layered on top of that infrastructure, a new set of incentives has emerged that increasingly rewards greater accountability. Even within the fee-for-service system, CMS carrot-and-stick pay-for-performance programs—meaningful use of EHRs, readmissions reductions, value-based payment and hospital acquired conditions penalties—have driven providers to focus on some critical aspects of quality and efficiency. Although each program may only involve a modest penalty, they grow over time and they add up quickly when taken together. In fact, over the next few years, hospitals could lose a portion of Medicare reimbursement for inadequate performance.

This is not say that we’ve come anywhere close to “figuring it out” when it comes to issues like performance measurement and health IT; we still have a long way to go. Although we certainly can’t demonstrate causation, it may not be a coincidence that remarkable reductions in cardiovascular, cerebrovascular and diabetes mortality transpired soon after the introduction and widespread use of standardized, intermediate outcome HEDIS measures for these conditions in the late 1990s. The challenge now is to take performance measurement to the next level.

With measurement infrastructure in place, the new payment and delivery models can be successful in driving the health care system toward true accountability for population health. In addition to widespread private sector experimentation, the myriad demonstration programs underway through the Center for Medicare & Medicaid Innovation (CMMI) offer unique opportunities for improving care coordination and fundamentally shifting payment toward a value-based orientation. What we learn from CMMI demonstration programs will help us to determine whether single bundled payment for episodes of care or population-based accountability through ACOs can really drive a different approach to care management and coordination. It is important to note that the Affordable Care Act gives the HHS Secretary the authority to convert CMMI demonstration programs to national payment policies should the CMS Actuary conclude that they save money (without harming quality), improve quality (without costing more) or both.

It is too early to tell exactly what these eventual models will look like, though it’s a good bet that differences from initial demonstrations will emerge. That makes an already messy middle ground a huge challenge for all stakeholders grappling with their new roles in the healthcare ecosystem. Yogi Berra may have been talking about the U.S. health care system when he said, “You’ve got to be very careful if you don’t know where you are going, because you might not get there.”

However, healthcare organizations that engage their clinicians and patients in helping to figure it out are much more likely to end up heading in the right direction.

Joshua Seidman, PhD, is Vice President at Avalere Health, and is now leading the new Avalere Center for Payment & Delivery Innovation. He also currently serves as President of the Society for Participatory Medicine. He can be reached at jseidman@avalere.com or found on Twitter @jjseidman

7 replies »

  1. 揂 song like this gets a very intense, emotional response,?Contreras says. 揥hether it was someone who served in Vietnam or the parents of children who have served in more modern conflicts, they all relate to it on some level.?

  2. you summarised very well the main problem of the whole health care system and these problems are not just limited to USA, even EU countries are struggling and will struggle more in future with ageing population, higher cost of new treatment and more demanding patients.
    still it is hard to translate the participatory medicine and patients engagement to the real medicine and real life.
    policies come from politicians and they are after policies that can grab attention of public eyes and enable them to get more vote for their next election.therefore they are looking for eye catching headlines and news that they can show off, gather attention and secure their position.
    i think the first steps will be reassuring politicians by investing more in research, studies and piloting programs to demonstrate that participatory medicine and patient engagement works and then they will look at these ideas as practical solutions that can save money and public will be happy and like them.

  3. Today, while I was at work, my cousin stole my apple ipad and tested to see if it can survive a 30 foot drop, just so she can be a youtube sensation. My iPad is now broken and she has 83 views. I know this is completely off topic but I had to share it with someone!

  4. The simple question I always come back to – what models work in the EU already? How do they get better outcomes, longer life spans, lower infant mortality rates, lower teen pregnancy rates, lower rates of bankruptcy due to medical bills (doesn’t exist) at 50% less cost?

    Why are we trying to reinvent the wheel? Do they have better trained docs? (no) Better tech? (no) more engaged patients? (not sure) Do they incentivize their health care providers more? (no)..

    Hmm soo what is it? 😉 (and no it isn’t single payer in France, Germany, etc)

  5. Every time I hear/read a blizzard of medical-industrial complex acronyms, I end it (in my head, at least) by singing “E-I-E-I-O!” [For the non-Americans, there’s a children’s nursery rhyme about Old MacDonald and his farm where each chorus – a litany of animal sounds – ends with ‘E-I-E-I-O!”] I like Josh’s IAC model, and also suspect there’s a lurking ICD-10 code for it.

    Having just returned from an informed consent/shared decision making confab at Dartmouth, I’m again struck by a sense that the medical industry has too long (forever?) seen its customers – people commonly called “patients” – as objects, not actors, in the medical transaction. The depth and breadth of complexity that the system has build in and around itself to preserve its “special” character (and its rising chunk of GDP, particularly in the US) is now weighing down any efforts it makes to connect with the people it serves.

    People/patients are more than capable of saying what their desired outcomes are in a medical setting. The challenge is to slow the clinical roll enough to HEAR them share their outcomes preferences. Anyone who can read can be a participant in their care. Asking someone what their budget is for [whatever], particularly in the face of cost-sharing and rising deductibles, would seem an ethical requirement, but it’s a rarely asked question.

    Why is the healthcare industry still struggling to figure out something the financial industry – also heavily regulated – figured out over a decade ago: how to make customer data (money) moveable at the customer’s direction, not just the bank’s?

    Here’s a pro tip: if you want to accelerate transformation, invite some experienced patients share their insights. Put them on your boards, hire them as consultants, make them part of your strategy team. You’ll be gobsmacked (in a good way) at what happens next.

  6. Josh, your summary of the VB (value-based) kitchen sink is quite well-done. Of course, it might be simpler if we could even arrive at an agreed-upon definition of any of these, and I’ll offer to share the driving with you on standardizing sequencing and measures. I want to add to your discussion in this way: WHO determines high-value (if that’s the measure of success)? If we continue to look only at the clinical performance–which HEDIS and other measures have done–then we miss the opportunities to build participatory medicine and arrive at sustainable outcomes. The contextual influences, what some call “social determinants,” as well as the ability to pay and the competence to choose, will be as much a factor in success as the clinical effectiveness.

    And I would add to Vik’s message to say, the financial out-of-pocket issues for patients/consumers is important, test, but the out-of-job, out-of-house, out-of-pension, etc., are just as important. As an example, recent publications have shown that women with breast cancer who are treated with chemo have more job loss (http://www.cbsnews.com/news/30-percent-of-breast-cancer-survivors-later-lost-their-jobs/). How and when does that figure into comparative effectiveness? Who is asking THAT question and what are the implications?

  7. If the alphabet soup is is maddening for people in healthcare, imagine how dreadful it is for consumers. And, the range is dreadfulness vary from just slightly dreadful for educated, connected consumers to downright appalling for people with neither the tools nor the connections to help figure things out or fix mistakes.

    As this alphabet gets remade and remade, it would be nice if someone remembered that, at some point, this must make sense to the people who use the healthcare system on daily basis, often with no guidance. They’re the ultimate stakeholder, financially and/or clinically, and they’re usually the last to know.

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