Value-based Care: Is it Working?
Thursday, June 7, 2018 | Ginger Biesbrock
Value-based care has been an area that I have found fascinating ever since I was first introduced to the concept in 2010. At the time, it made so much sense—creating an environment where the keys to effective patient care are incentivized and resources are available—yet it seemed elusive. Almost 10 years later, we have many different ‘value’ type models emerging both in public and private payer sectors, but I wonder if we are really seeing the results that we were hoping to get.
As I reviewed CMS reports, editorials, and white papers, several findings caught my attention. First, a recent report regarding the performance of the Center for Medicare and Medicaid Innovation published by the Government Accountability Office in April of 2018, outlined that the Innovation center in 2014-2015 had exceeded participation from both Medicare beneficiaries and provider participation in Accountable Care Organizations. The actual shared savings of these programs did not meet goal, yet 34% of the participants in these did experience shared savings. So, one third were considered successful in the cost category? A 1/3 success rate and data presented in 2018 on results from 3-4 years ago does not seem like a great way to run a business. However, as you can see below, their attempt to find the right model(s) is continuing to progress with 37 different models implemented in this calendar year and $54 billion being allocated to the work for this year’s budget.
Another interesting report released earlier this year on the 2016 results of the Medicare Shared Savings Programs (MSSP) found that after reviewing more than four years of cohorts, the true savings began to emerge on average at year four. It was in year four that the savings against benchmarks were less than the shared savings payments. However, success was not had by all, with many dropping out after the first year or two. In fact, of the 106 ACOs that started in 2013, only 74 remain—proof that value-based work (in this case MSSP) is hard work and not all will survive. One author quoted “A certain destruction is necessary in this new, competitive value-driven healthcare world.” (Boome, AJMC, Oct 2017)
My next question is whether or not these programs are producing quality results. That’s the other half of value, right? CMS has noted that for measures that exist in both ACOs and FFS, the ACOs consistently perform better. Also, those ACOs receiving savings did better on quality than those that did not receive savings. So, based on the current quality metrics measured, the lower costs are not necessarily jeopardizing quality. In addition, according to the GAO, studies have found that higher levels of spending do not reliably lead to enhanced quality of care. Now, much of the savings in the ACOs to date is related to reducing redundancy and over utilization. While unnecessary care has been reduced, I wonder if we have really yet changed our delivery model or have we just cleaned it up a bit. It will be interesting to see what happens in years 5 to 7 as well as for those that start to take downside risk (as most to date have just been upside risk).
Another question to ask: are we looking at the right measures for true quality? CMS did launch a new initiative in 2017 called Meaningful Measures that is meant to work on developing and refining measurements. (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/CMS-Meaningful-Measures_Overview-Fact-Sheet_508_2018-02-28.pdf).
I would argue that this is a very much needed initiative as we have seen some not-so-great results in areas that we considered quality measures. You may have all seen the article in JAMA released in early 2018 that questioned Heart Failure patient outcomes with the readmission reduction program showing that although readmissions have decreased, mortality has increased – unintended consequences. The 30-day risk adjusted readmission rate went from 20.0% to 18.4% during the penalty phase and the mortality increased from 7.2% to 8.6% (JAMA Cardiol. 2018 Jan 1;3(1):44-53. doi:10.1001/jamacardio.2017.4265). A lot of great work has been done with the RRP, with as much as $250 billion in savings for unnecessary readmissions. However, the authors of this article question whether quality metrics such as readmissions create an environment where we take our eye off the mark. We spend a lot of time doing ‘short term’ type work that does not equate into truly improved outcomes. Another article in JAMA from 2017 also noted that CMS has actually placed a higher value on reducing readmissions than improving mortality rates based on their penalty math. Under the Hospital Value-Based purchasing program, high mortality numbers cost a hospital 0.2% of its Medicare payments, compared with a 3% penalty under the Readmission Penalty Program. Forgive me for mixing my ‘value’ programs, but I do think that the point I am trying to make is a good one. As any of these programs evolve, the administrators of the programs need to keep their sights set on the consequences. Are we really getting the results that we are looking for?
Finally, the last interesting finding I discovered is that ACO programs that are physician-led have better success rates as far as shared savings than those that do not include physicians. Nearly half (45%) of physician-only ACOs earned shared savings, while only 23% of ACOs that include a hospital earned shared savings. Of course, we would have seen this coming all day long. Those that provide the care on a daily basis will have the best insights on how to improve the care in a cost-effective manner. Interestingly, I have been in several organizations discovering that there was some sort of value-based program in place at the hospital level that the physicians knew nothing about. As you can imagine, these programs were not successful.
At the end of the day, I am still a huge fan of value-based reimbursement models. In fact, Federal spending on healthcare in the US is expected to reach over $1 trillion this year; to continue to increase meaning we have to continue to push to do what we do differently. Our current state is not sustainable. I would also note that those of us who have provided care in a fee-for-service world know that resources for care management, care collaboration, patient engagement, among others were all scarce, as these were not reimbursable type activities. It is really hard to do the right thing in a fee-for-service model when the right thing is effective patient care that spans the continuum and improves outcomes months and years down the road.
I think that several key principles are emerging from the few learnings that are out there. First, the number of programs and participants are increasing (including additional funds allocated), proof that value-based programs are not going away any time soon. Second, we need to be careful with our quality measures and the structure around the programs – ongoing research and monitoring is extremely important to assure that we truly are getting and incentivizing the outcomes that we desire. Third, including the providers in these programs is key in succeeding both clinically and financially. Finally, it is not for the faint of heart; it requires patience, perseverance and hard work.
And now I plug the power of our network and our voice. We, the MedAxiom Community, have ability to share with each other our experiences, what is working and what is not. We have the ability to advocate and influence our healthcare policy makers at the Federal government level and build innovative programs with our private payer partners. I have always said that cardiology seems light years ahead of our non-CV team members when it comes to moving the needle. We have power and I encourage you all to continue to move forward in your worlds – creating better delivery models, the right incentives for your teams, and keeping the patients at your center of everything you do. Godspeed!
Illustration: Lee Sauer
About the Author
Ginger Biesbrock, PA-C, MPH, MPAS, AACC, is Senior Vice President, MedAxiom Consulting. She is a respected executive, provider and teacher with 20+ years of experience in the health care industry with a concentration in clinical care and operations. Before joining MedAxiom Consulting, Ginger was Director of Operations at West Michigan Heart, a 39 Physician practice with 24 mid-level provider. At West Michigan Heart, Ginger oversaw all operations for ambulatory services, tertiary care and rural health practices. Prior to that Ginger was the COO of the Cardiovascular Group at Centra-Health.
Her areas of consulting expertise include APP Utilization, Care Team Optimization and Transitions of Care.
To contact, email: email@example.com
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