Three takeaways on value-based care
Or what I learned from 24 hours in Miami
The first patient I ever helped care for was a young pregnant woman who drove herself to the emergency room with a sudden pain in her stomach. She worked as a waitress just a few miles away from Rhode Island Hospital where I was a medical student. Like many of the people I saw that day, she didn’t have health insurance. This was the mid-2000s, before the Affordable Care Act was passed.
Fortunately, her pain was not a pregnancy complication and it passed after a few hours of observation. Unfortunately, the ultrasound and battery of blood tests we ordered ran her medical bill to thousands of dollars – far exceeding the cost of her monthly rent.
The Affordable Care Act was designed to ensure that people like her have access to health insurance. It was also designed to incentivize the health system to actually control the costs of care by tying more of the payments to health outcomes. In the 12 years since it was passed, we’ve made more progress on the former than the latter. Tens of millions more Americans now have access to at least basic insurance coverage. But total costs of care continue to rise inexorably and 2022 is the least affordable health care has been for the average American in decades. The rub is that we don’t even seem to be getting value for all the spending.
Healthcare expenditures represent one-fifth of US GDP — $4.1 trillion — nearly twice as much as a share of the economy as the average OECD country. And yet, we have the lowest life expectancy, the highest chronic disease burden, and the highest rate of preventable deaths. The gap between what we spend and get is particularly egregious in maternal health. Just the hospitalization costs for childbirth account for 0.6% of GDP — that’s $123 billion — yet pregnant people are 50 percent more likely to die giving birth today than their own parents a generation ago.
I’ve been to more conferences than I care to count about what to do about this, and rarely hear much that is new. Recently, I had the privilege to join three of the smartest people in this space at the ViVE Conference in Miami — Dr. Julian Harris, CEO of ConcertoCare; Aneesh Chopra, President of CareJourney; and Rani Khetarpal, head of value-based partnerships at CVS Health. This conversation felt different from all the others. Here are three takeaways:
There is no improvement without equity
In health care we often pat ourselves on the back for improving care “on average,” even while certain groups are left further behind: women, people of color, pregnant people of color. Hence we continue to see patterns such as in California: even while making strides in improving maternal mortality, the disparity between white and Black mothers has persisted.
At the end of February, the Biden Administration unveiled ACO REACH, the next iteration of the direct-contracting model that holds large health systems accountable for achieving better care at lower cost. A key feature is the emphasis on equity and community health, moving the health system in the direction of being measured and paid based on closing gaps. As Aneesh noted during the panel, the program incentivizes the recruitment of patients who are currently underrepresented within value-based models. It also widens the path to ensuring value-based care reaches greater scale among Medicaid populations, which has seen significantly less use of alternative payment models to date (CMMI has articulated a goal of having every Medicaid member and the majority of Medicare members to be in some form of value-based arrangement by 2030).The whole point of payment reform is delivery reform
When people talk about health care reform they are often conflating two things: payment reform and delivery reform. Policymakers usually lead with payment reform and assume that clinicians will simply adapt and provide care differently. But as I pointed out on the panel: policymakers are often like astronomers looking through a telescope and a planet that clinicians live on, and clinicians are the masters of the “work-around.” Carrots and sticks just aren’t that effective in isolation. Instead we should focus on building the care model that delivers value for the patient, and then attaching the payment design that makes sense.
A case in point from my life as a surgeon: C-sections are up almost 500% in the US since the 1970s and are now the most common surgery in the country. C-sections are generally extremely safe, but they are associated with higher rates of complications — and they are expensive for payers. So you might think that simply reducing the price we pay for these procedures (which see extreme variation depending on who pays for a patient’s care) would reduce the cost of maternal care in totality — and maybe even reduce their prevalence. In fact, research shows that vaginal births are significantly more expensive for providers — the third piece of the equation — because of the time and staffing needs required.
A better approach, then, is to start in reverse. Make people healthier. Define episodes of care with clear bounds (like, say, pregnancy and delivery) and then build a payment system that incentivizes the right actions from an integrated team over the course of the episode. It’s care delivery reform that has to lead, with payment reinforcing what we know from evidence is proven to work.
This is the approach we’re pursuing at Maven.“Taking on risk” isn’t scary if your results are reproducible
‘Taking on risk’ is industry jargon for being responsible for health outcomes. The word ‘risk’ is scary — but that’s also sort of the point. Our panel talked about ways to make it more palatable with an incremental approach – organizations taking on 50 percent of the downside risk, for instance, rather than the full burden. As Julian noted, the shift to value is too slow across the country, and allowing for this intermediary step is pragmatic. But as Rani stated simply, “value-based care is about risk.” If providers and payers are unwilling to have skin in the game, the whole approach falls apart. By contrast, staking real revenue on making people healthy helps ensure that care models are built on sound scientific principles like validity and reproducibility.
Digital health accelerates our ability to design and deploy care models at scale. In the absence of value-based care, the ecosystem is filling with “solutions” that don’t help people become healthier. Vendors can trade on people’s anxiety about their appearance or their fertility and make money in the process. But in a value-based paradigm, you have to be grounded in evidence to get paid.
On one hand, value-based care is a wonky subject. But as Aneesh said at the end of our panel, “if not value-based care, what?” Fundamentally, the shift to value should help the healthcare industry with our growing crisis of trust, and refashions the system around the people we are meant to serve. Thanks to the ViVE team, all of my co-panelists, and our moderator Natalie Davis of United States of Care, for the awesome discussion.
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What my team is reading, considering, and building against
The WHO reports that at least 18 healthcare facilities have been attacked during the unjustified Russian invasion of Ukraine, including what is reported to be a maternity hospital in the city of Mariupol.
If you are looking for some way to help, Voices of Ukraine is supporting children and families displaced by the war.The CDC released its annual report on the state of maternal mortality in the United States, showing a 14% year-over-year increase in maternal deaths, with nearly all of the increase attributable to Black and Hispanic women. Coming in the midst of a global pandemic where we know that pregnant people have lagged in getting vaccinated, this increase isn’t necessarily a surprise, but it’s still shameful. The disparities we see are a striking indictment of both our public and private sectors. A way forward starts with listening to patients, and then carrying their voice into the products we build and the policies we create.
This is a thoughtful qualitative study related to equity, digital health, and language. The authors interviewed patients and providers at two federally qualified community health centers with large immigrant populations, where the predominant languages spoken by patients were Spanish and Chinese, about their experiences using telehealth. They identified issues related to both experiences: providers had challenges integrating different digital services to deliver care effectively, while patients often had trouble downloading software and launching virtual visits. Having ready access to a provider who speaks your language regardless of where you are is an exciting and powerful application for telehealth, but as this paper shows, there is still friction in many circumstances even when the right services are being utilized. At Maven, we have seen promising results from member use of simultaneous translation technology, but as this paper shows, ensuring that a network of providers is representative of the patient population being served is still the foundation for effective care.
I’ll close by paying respects here to Dr. Paul Farmer, who passed in February. His was a remarkable life of service and just plain doggedness on behalf of the most vulnerable people in the world. And while many of the tributes authored in recent weeks have been wonderful, I offer Paul’s own words here, which articulated his personal credo of accompaniment. It is as good a description of humanity I have read of late, and with the world such as it is, I’m glad to share it: “To accompany someone is to go somewhere with him or her, to break bread together, to be present on a journey with a beginning and an end,” he said. “There's an element of mystery, of openness, in accompaniment: I'll go with you and support you on your journey wherever it leads.” Thank you, Paul.