By MICHAEL MILLENSON
Health care’s much-trumpeted transition “from volume to value” care remains more tepid than transformational, according to a new study. Looking at 22 health systems nationwide, RAND researchers found that compensation continues to be “dominated by volume-based incentives designed to maximize health systems revenue.”
Although confusing payment schemes bear part of the blame, there are deeper problems that appeared in sharp relief when I chanced upon a long-ago PowerPoint from a prominent political strategist and early advocate of “data-driven reimbursement.”
I refer, of course, to Newt Gingrich. His recommendations from 2007 about designing transformational change in health care provide a perspective that remains useful today in addressing what is ultimately a political problem. Frankly, value-based care (VBC) advocates perform dismally.
Going Along the Gingrich Roadmap
Back in 2004, Gingrich and I both served on a commission seeking to improve the quality of long-term care. This was during a period when a neutered Newt, out of power, was undergoing a political makeover by championing bipartisan health reform ideas such as electronic health records (EHRs) and evidence-based care. He even shared an award from NCQA with then-New York Sen. Hillary Clinton.
What Gingrich also shared, often, were his thoughts about what was necessary to drive the kind of sweeping alteration of the status quo represented by his leading Republicans to their first House majority in decades. Reviewing that roadmap, it’s not surprising that VBC advocates remain far from their destination.
The journey starts off in the right direction, with VBC advocates following Gingrich’s advice to “focus on large changes.” Trying to upend the way physicians have been paid since Hippocrates made his first house call certainly qualifies. But ambition has to be articulated as part of an organizing and attractive vision.
In 1997, in a book called Demanding Medical Excellence, I summarized the urgency of what we now call value-based care this way:
Tens of thousands of patients have died or been injured years after year because readily available information was not used – and is not being used today – to guide their care….(The health care delivery system) must be restructured according to evidence-based medical practice, regular assessment of the quality of care, and accountability.
In a similar vein, Gingrich in 2007 emphasized “a clear and compelling vision for quality” that would appeal to patients and medical professionals by promising safe care (no preventable deaths or injuries); consistent clinical excellence (appropriate and effective evidence-based care); and clinicians and staff partnering with patients.
Language That’s Bureaucratic, Not Bold
In contrast, the coalition sponsoring last month’s Health Care Value Week positioned transformation as a series of “models” addressing a bureaucratic checklist of health care “challenges.” The same type of language is used by the Centers for Medicare & Medicaid Services.
Even what the policy community believes are catchy labels may resonate very differently with ordinary people. “Value” care sounds like the medical equivalent of a meal at Taco Bell. (Also, if your child falls sick, do you want “best care” or “best value for the money”?) “Accountable” care has overtones of treatment decisions made by CPAs. And a “medical home” is where Mom says she’d rather die than go to.
What is glaringly absent is a clear vision of a health care system where sick people are not injured, killed or suffer economically in ways we know how to avoid; where there is an explicit emphasis on maintaining health; and where clinicians and health care organizations are enabled and rewarded for achieving these goals.
Unfortunately, “health maintenance organization” was already taken.
The Case That Could Be Made
The reluctance to present straightforward arguments for VBC is particularly frustrating in light of recent studies in JAMA Health Forum and JAMA Open that highlight current system failures.
For instance, when an organization exits a VBC program such as a Medicare accountable care organization, provider behavior changes along with payment. There were fewer preventive services and “lower quality of care,” a University of Michigan-led team concluded.
In a similar finding of current incentives’ impact, Johns Hopkins researchers singled out “investor ownership” of hospitals as an important factor in the overuse of 17 different (!) “low-value” medical services. This, at a time when the Wall Street Journal has chronicled the growing ownership of hospitals by private equity firms.
But perhaps the greatest effect on individual patients from the lack of feedback or accountability mechanisms was shown in a study led by Harvard researchers that analyzed the records of nearly 9,000 physicians treating commercially insured patients. The results, although part of a long-known pattern, are still startling.
Pregnant? Your odds of getting preventive care as simple as prenatal screening from your obstetrician vary from a low of 31 percent to a high of 94 percent. Heart disease? The chances your cardiologist gives you needed statins to vary from 31 percent up to 71 percent. (Results were adjusted for the patient’s clinical profile.)
But the most jarring variations related not to what wasn’t done, but to what shouldn’t have been done, but was; i.e., care without value. For instance, among patients with newly diagnosed osteoarthritis of the knee or the hip, the top-ranked quintile of orthopedic surgeons, following professional guidelines, performed an arthroscopy just two to three percent of the time. The bottom quintile of surgeons used the arthroscope 31 to 66 percent of the time.
As for patient safety, a separate study found that professional guidelines meant to reduce surgical infections are not being followed over a third of the time. This severe lapse is exposing thousands of Americans to possible “life-changing” consequences such as prolonged hospitalization, sepsis or even death, according to the study’s lead researcher.
A Willingness to Subvert the Status Quo?
Sixty years ago, science historian Thomas Kuhn wrote a groundbreaking book about what it takes to change an established paradigm. Kuhn demonstrated that logical appeals to evidence don’t work, even with scientists. Instead, paradigm change only occurs when defenders of the old ways can “no longer evade anomalies that subvert the existing tradition.”
Bringing accountability to a medical culture that prizes autonomy, whether done through systemic professional feedback, financial incentives or both requires a genuine paradigm shift. Unfortunately, attacking the status quo of misplaced incentives, ingrained habits and an absence of good information systems is much trickier than proclaiming, “Paper kills,” Gingrich’s pitch for EHRs. There are no easy villains – greedy insurers, rapacious drug companies, high-priced hospitals, or a lack of “consumerism” – to blame.
Moreover, as Eric Patashnik, a Brown University professor and co-author of a book on the politics of evidence-based medicine, told the Washington Post, the public assumes doctors already do the right thing. “The political constituency for evidence-based medicine is weak.”
Certainly, a coalition of provider groups (and others dependent upon their goodwill) is never going to attempt to whip up public support by vividly describing a current-state system riven with crazy-quilt practice variation and tolerating persistently unsafe care. The wiser course is to describe “better quality” with touching anecdotes about home visits by nurses.
There’s another important problem, not spoken about publicly, but epitomized by the RAND study mentioned earlier on compensation. Consider Gingrich’s admonition that a vision of transformational change “must be functionally accurate – you must ‘walk your talk.’” Now, look at the organizations sponsoring Health Care Value Week. How many of them or their parent organizations still depend heavily on revenue maximization from high volume and high prices?
Democracy’s Deus Ex Machina is Government
Do these factors mean that the move from “from volume to value,” first promised in the Affordable Care Act in 2010, is only slightly more likely than New Newt (v. 2022) reuniting with Hillary? Allow me to suggest a slightly sunnier scenario.
Gingrich’s pro-computerization push worked not only because he was going “with the tide of societal change,” as his strategy outline put it, but also because many others supported the same goal. Even that larger effort ultimately succeeded, however, only after the economic crisis of 2008 prompted federal intervention. With the HITECH Act, the government authorized billions of dollars in payments to physicians and hospitals to subsidize the switch to EHRs.
VBC, however abysmal its advocates’ communication efforts, nonetheless commands strong and broad-based support due both to self-interest (to prevent possibly more radical solutions) and genuine selflessness (it’s the right thing to do). As a result, I believe that the federal government, with private sector support, will via subsidies or mandates do for VBC what was done for EHRs when the opportunity arises. One can only hope that hard lessons learned from the EHR experience will inform the VBC one.
At the Value Health Week summit, Dr. Farzad Mostashari, Aledade’s founder and the former head of the Office of the National Coordinator for Health Information Technology, pointed the way forward. Said Mostashari: “There needs to be a sense of inevitability.”