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The industry-wide transition to value-based care was never going to be quick or easy. But both payers and providers may be better equipped for success than they think.
The move to value-based care is a seismic shift in the U.S. healthcare system. Transforming a system in which we pay for the volume of visits, services, and procedures to one in which we pay for quality and outcomes is a massive undertaking for payers and providers alike. It requires big changes, such as totally rethinking how we deliver and bill for care.
But while it is impossible to change 20 percent of the U.S. economy overnight, we can make significant inroads just by starting with three commonsense changes. These are things most people agree we should be doing, but within today’s complex healthcare system, they simply do not happen. Each of these solutions pulls more than its own weight in value and results, leading to an outsized impact on quality of care, health outcomes, and total cost.
First, we need to focus on the biggest cost drivers.
In our current system, a select few conditions have a disproportionate effect on health outcomes and total costs. For example, chronic conditions, which impact six in 10 American adults, are the top driver of national healthcare costs. In fact, diabetes alone costs the U.S. $245 billion every year, while heart disease and stroke account for $190 billion per year. But there is power in large numbers; just a small percentage change in outcomes and efficiency for any one of these chronic conditions can have a massive improvement on the healthcare system.
Chronic kidney disease, for example, affects 31 million Americans and costs the U.S. more than $100 billion each year. In fact, while Americans with kidney failure account for only one percent of the Medicare population, they are responsible for over seven percent of all Medicare spending. But despite the massive costs associated with kidney disease, we currently treat it in an almost entirely reactive and uniform way. As a result, most people whose kidneys fail end up on costly, in-center dialysis-88 percent, in fact.
Providers and payers can begin to tackle the huge health and financial costs directly and indirectly linked to kidney disease by encouraging patients to choose alternatives to in-center dialysis. Accelerating access to kidney transplants, fully supporting palliative and conservative care, and promoting in-home and self-care dialysis therapies can save tens of thousands of dollars per patient each year. Simply by considering alternatives to the status quo, we can begin to make measured improvements in both care and cost.
Second, we need to think ahead and act now, so we can save later.
It is no secret that our fee-for-service system creates little incentives for preventive care. The power of value-based care is that it reorients the system to deliver “healthcare,” rather than “sick care.” But, to succeed in a value-based model, providers and payers must understand and accept that, in some cases, investing resources to deliver more care early on can lead to better health outcomes and lower costs down the road.
Coming back to kidney disease, it is clear that early intervention can yield significant reductions in cost. But today’s healthcare system does little to nothing to identify those at risk of developing kidney disease until it’s too late. In fact, nine out of 10 people with stage 3 kidney disease don’t even know they have it.
It doesn’t have to be this way.
Kidney disease typically takes years to progress and has clear risk factors, including age, family history, high blood pressure, and diabetes. Knowing this, providers and payers can use wellness visits to learn more about their patients’ risk, harness data analytics and population health tools to identify and track those most at risk, and employ care management techniques to better equip patients with the tools to live stable, healthy lives.
Today’s system forsakes patients by waiting to act until their kidneys fail. But it’s common sense that patients-and the system as a whole-would be much better off if we help them avoid kidney failure in the first place.
Third, we need to look beyond medicine to save healthcare dollars. Preventive care and early diagnosis are powerful tools in value-based care, but sometimes it’s not what happens to patients inside the doctor’s office that has the biggest effect on their health. Truly caring for a patient's total health requires caring for their lives beyond medicine.
Social determinants of health are increasingly recognized as important factors in controlling health care outcomes and costs. For providers and payers, this means asking the right questions about patients: Do they have transportation to their medical visits? Can they afford their medication? Does their diet, home, or workplace present health risks? Only by answering questions like these can we set patients, and our healthcare system, up for success.
Of course, patients have questions too. That’s why another key factor in value-based care success is patient education. Providers and payers must devote resources, such as care managers, health coaches, and decision aids, to ensure that their patients have the resources and knowledge they need to make informed decisions about how best to manage their health and treat their condition.
The industry-wide transition to value-based care was never going to be quick or easy. But both payers and providers may be better equipped for success than they think. A few basic changes in the way we deliver care can lead to downstream improvements in quality, outcomes, and costs throughout the health system. By considering patients’ total health without losing sight of major cost drivers, acting early and often to prevent complications and costs, and thinking about patients’ lives beyond healthcare, we can all begin to make the promise of value-based care a reality.
Robert Sepucha is chief administrative officer of Cricket Health, a specialty care provider of integrated nephrology and dialysis care for people with chronic kidney disease (CKD) and end-stage renal disease (ESRD). Sepucha previously led government affairs, strategic communications, and industry outreach at Fresenius Medical Care for nearly a decade.