Value-Based Care is Not Dead

Being a contrarian can be fun, but there is a difference between being critical (even skeptical) and being a cynical misanthrope

In an October 15th article published by HFS Research Limited (https://www.hfsresearch.com/research/care-is-dead-focus-one-generation/), the executive research leader starts off by saying value-based care is dead.? While he raises several good points regarding the history of value-based care, there needs to be recognition it is in a constant state of evolution.? In my opinion there is a lack of depth of understanding however, regarding the early days of managed care and political management, as well as the beginning shifts from traditional fee for service healthcare in traditional settings to the early experiments in healthcare resource management.

There are several points with which I agree, the primary being that while government is in the position to drive payment and coverage policy, politicians are not qualified to dictate care.? To paraphrase, "all healthcare is local."? And while we may agree the aim in value-based care is to align the interests of the stakeholders (patient, provider, payer) in achieving outcomes, how we define those outcomes is highly variable and context dependent.

Simply put, Value=Quality/Price.? But that begs the question:? how do you define Quality? Over the years, "quality" has been rigidly defined as performance against metrics such as HEDIS; e.g. How many of such and such tests did you perform for the applicable population, or how few of these inappropriate tests did you perform? This was the essence of P4P - the early days of value-based care.

Parallel with this, value-based care began to look at "squeezing the denominator" - lowering cost.? On a population basis, this looked a lot like the 1990s in the days of the "HM-nO," rationing care and using UM as a weapon.? The more recent and evolved way of looking at this is attempting to eliminate "low value" care - that care which does not conform with the best practice, evidence-basis.? The system relies heavily on shifting the financial burden to those who prescribe the care; ostensibly creating incentives for limiting waste while sharing in savings.? The author's assertion that we are asking providers to manage financial risk fails to recognize that high-value care is typically financially responsible care.? Eliminating waste inherently manages financial risk.? The statement that "VBC makes providers poorer and patients sicker" demonstrates a lack of understanding of what motivates those of us who dedicated our lives to medicine, who strive to do what's right and best for patients, and further demonstrates inexperience with the mechanics of a properly aligned value-based system.

So, let's return to the definition of "value."? It's essentially whatever the stakeholders are attempting to achieve at the moment.? And ultimately that's the ambiguous part of value-based care.? It's the determination of what's of value to the stakeholders, and that's a shifting landscape.? Hopefully, it's qualitatively the same for all the stakeholders - optimal health.? But what's considered "optimal" for one individual may not be the same as for another.? "Value" boils down to those metrics that are deemed to be reflective of "optimal" health.

The difference between the vision of value-based care in the mid-1990s and now is an evolved understanding of the dynamics of healthcare, the availability of data, and sophistication of the analytics.? I'll use social determinants of health as an example.? For at least four decades we've known that social determinants were important.? We learned how to measure them but lacked the ability to make meaningful use of those data.? Perhaps two decades ago we began to categorize social determinants, but still had no idea of which ones were important, and if we did indeed "move the needle" on one of them, was that going to achieve the outcome for which we were looking.? We still didn't have the answer to "I know what I CAN do, but what SHOULD I do?"? "Where's the ROI?"? With more advanced data analytics, machine learning and the ability to handle big data in healthcare (going back a dozen years or so) we are now able to predict where we can and should devote our resources.? These data, and the increasingly precise insights we can achieve to better understand our populations, support the ongoing relevance of value-based care.? This results in both better numerator (quality) and denominator (price) management.

While many of the author's points are valid, I believe his overall construct is not:? value-based care is not a discrete program or government model.? It's an evolution.? Ultimately, "value," as David Eddy said in the '90s, comes down to value judgements.? Is it valid to impose one set of values on a population; to assume and impose what they should consider of value?? Who decides?? Do we adopt a philosophy of generalized utilitarianism - the greatest good for the greatest number - as we exercise fiduciary responsibility for the resources of the healthcare system?

Let's not throw the baby out with the bath water.? Value-based care is far from dead, it's an aspirational vision that continues to evolve.