Today, every aspect of human need is defined by a key factor: value. Medical care, being an essential need, is no different. From a fee-for-service (FFS) model, that is ‘one-time’ in nature, healthcare is heading towards a more comprehensive and patient-centered approach of value-based healthcare (VBHC).
This shift is gaining rapid momentum, so much so that VBHC as a market was valued at $6.07 billion in 2022 and is predicted to reach $32.69 billion by the year 2031. The wider deployment of this model is being effectuated by the varying needs of the different stakeholders in the healthcare continuum – providers, payers, and policymakers. This is also a sign that all these parties are placing the most important member of this system at heart: the patient.
Shaping a patient-centric healthcare ecosystem
A survey found that 44% of providers and 23% of payers cited the improvement of health and wellness of their targeted populations as their top priority. This is indicative of the fact that the adoption of VBHC is resulting in a holistic transformation of the healthcare ecosystem, and how?
Shift from clinical outcomes to patient outcomes
Conventionally, the outcomes experienced by patients after a course of treatment or medical procedure have been viewed from a clinical standpoint, where it is focused on the ‘before and after.’ For example, the improvement in an individual’s condition after undergoing a hip replacement surgery would be measured by whether they feel less pain and difficulty in movement. However, with a value-based approach, the emphasis is now also on ensuring that the patient has a greater range of motion and increased functionality that improves their overall health.
Synergy between multiple stakeholders to deliver more value
A marked movement from FFS to VBHC is possible only if there is increased collaboration between the various stakeholders. From healthcare providers to payers and insurers to policymakers and regulators, all stakeholders are increasingly working together to deliver maximum value to patients. Through alignment of incentives, sharing of knowledge, and leveraging of technology, among other efforts, healthcare institutions are increasingly promoting patient-centered care.
Transition from generic medicine to specialized care
A ‘one-size-fits-all’ approach to healthcare is being replaced by specialized care because of VBHC. Patient-specific care through personalized treatment plans and personalized medicine is fast becoming the norm. Importantly, subspecialists such as oncologists, cardiologists, and neurologists, among several others, have become more accessible to patients. For example, if a patient exhibits symptoms of renal disease, the growing flexibility of the VBHC framework enables direct access to a nephrologist rather than taking a long generalist-to-specialist route.
Enhancing the delivery of value
Delivering value to patients is an intricate interplay between various factors, from metrics used to measure value to the pitfalls in their execution. However, achieving harmony between them can help enhance the quality of care delivered. Let’s look at the metrics used to evaluate value.
- Safety of care: Models to measure patient safety are integrated into VBHC. This includes treating the prevention of secondary infections, preventable hospitalizations, and related factors as key quality measures. According to the WHO, 80% of all primary and outpatient adverse events are preventable. Hence, safety is a key metric.
- Readmissions: The duration of readmittance following hospitalization is a critical outcome measure. An example of this metric in action is the provision in CMS’ Readmissions Reduction Program (HRRP), where hospitals are penalized if their readmission rates of patients within 30 days of discharge are high.
- Patient experience: Patient-reported outcome measures (PROMs) are an important metric to ascertain whether specific treatments have enhanced patients’ quality of life. CMS lays emphasis on the measurement of PROMs to reward the performance of healthcare providers and physicians for improving outcomes for patients.
- Timeliness and access: Ensuring that patients receive timely care and reducing the number of barriers that delay the provision of treatment is another vital quality metric. From shortened wait times to ease of booking appointments, measures to fulfill the preventive aspects of VBHC are essential. The Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) Model stresses on this aspect of VBHC.
As a result of the complex and interrelated nature of the VBHC framework, the above-mentioned metrics influence other metrics such as mortality, cost and resource utilization, and effectiveness of care, among others.
Challenges Affecting VBHC
The metrics in place bring with them their own set of challenges. Particularly, the management of contracts is affected significantly by them. Some of them are:
Absence of Standardization
Several of the metrics in place measure aspects of care that are similar. Yet, they utilize benchmarks and scoring methodologies that are varied. This can give rise to an excess of data and complications in its interpretation. For example, providers associated with VBC program contracts will view identical metrics applied to different sets of populations and payers along with different benchmarks and methodologies. This can complicate the evaluation of metrics in terms of commercial versus government programs.
Complicated Measurement Systems
The complex measuring systems–marked by different benchmarking scales, percentage schedules, and point systems–make the achievement of commonality difficult and make the process of tracking and auditing metrics challenging. This also affects the providers’ ability to identify areas, both financially and clinically, that require refining, thereby affecting contracts.
Gap Between Clinical and Financial Outcomes
The various stakeholders of VBHC, more than often, are proficient at either measuring financial results or clinical performance at a metric level. Unfortunately, there is no balance between the two. This makes it difficult to link contracts’ financial results with the actual clinical outcomes. As a result, the alignment between the various parties is impeded.
Systemizing the VBHC Ecosystem
Like any complex system, VBHC is evolving and growing. The stakeholders in the care continuum are constantly learning and refining their processes and, by extension, the overall ecosystem. Below are some of the strategies to ensure a streamlined VBHC ecosystem is in place.
Identify high-risk patients
The purpose of VBHC is defeated if high-risk patients are not identified and provided timely care. Data on these populations can be gathered through annual doctor visits, self-reporting of wellness on online portals, and other methods. With the help of a healthcare data platform, the data can be transformed into actionable insights that can help detect high-risk populations and suggest beneficial interventions. This includes new treatment plans, referrals to specialty care, and wellness programs, among others.
Addressing gaps in the delivery of care
Unlike FFS, where care is ‘episodic,’ VBHC provides greater scope for addressing overall patient outcomes. In the case of patients who seek regular check-ups or follow-ups, it is easier to spot and address the gaps in care. On the other hand, for patients who approach healthcare professionals only in the event of acute illness or injury, this process is challenging. Nevertheless, such visits can be turned into opportunities to bridge the care gap. From verifying pending preventive care options to scheduling screenings, there is much that can be accomplished.
Communication between stakeholders
The interdependent nature of VBHC demands better communication between various stakeholders. From providers to payers and members within a network, transparent communication can save both time and costs. For example, communication between care providers in the same network can help prevent overlaps, or staying in touch with provider relations representatives can provide physicians and hospitals with updates on their scoring systems and changes in incentivization.
Secure sharing of data
This can have a direct impact on the above-mentioned areas as well. The availability of patient data – with the assurance of privacy – can maximize patient outcomes. For example, access to patient data between various stakeholders in the VBHC network can ensure that a patient receives specialized and customized care and services on demand.
Adding value at every touchpoint
The gravitation of the healthcare ecosystem toward VBHC signifies a transformative approach that prioritizes the well-being and satisfaction of patients. Despite existing unworkabilities, this approach continues to evolve and undergo refinement. With its various stakeholders working together to make patient-centric care a growing reality, it is safe to say that the future of healthcare, without a doubt, is a value-based one.