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What do we mean by value-based care?


Consumers and health care providers often define the term differently. But the focus for both groups should be on health maintenance and disease prevention.

The term “value-based care” has been a fixture of the U.S. health care lexicon for more than a decade. Value-based care became institutionalized when the Medicare Improvements for Patients & Providers Act and the 2010 Affordable Care Act established several programs to incentivize providers to reduce hospitalization rates, and by extension, lower costs.

Since then, achieving a value-based model in the U.S. has been prioritized by many advocates across the ecosystem. The problem is, there is a major disconnect between how patients define “value” and what insiders mean when they refer to value-based care. Patients often initially equate the word “value” with “cheap,” and many struggle to understand the complexities behind the cost of care. There is also a lingering notion in the U.S. that you only need to engage with your health care providers when you are ill.

While lowering costs should certainly be a central element of value-based care, the conversation needs to shift more toward working with patients to establish effective strategies for health maintenance and prevention. In other words, value-based care should be about keeping patients healthy, as opposed to waiting for them to get sick and then providing treatments that are likely to be costly. The health care industry needs to better align with consumers around this notion and their broader perception of what constitutes value.

So how do we get there? The reality is that it requires evolution across the entire health care industry, from providers and payers to industry and government. Primary care physicians (PCPs) in particular have an opportunity to drive these efforts. Why? Because when patients are pressed to define “value” in health care, their answers are more likely to reflect the importance of their relationships with their doctors than they are to focus on cost. For example, a 2020 survey of 745 patients with cardiovascular disease found that the most frequently cited determinants of value in the health care experience were “communication with health care providers” and “trust in my health care providers.”

PCPs are well positioned to form those trusted relationships because they often see patients when they are healthy for services such as annual physicals or treating minor injuries or illnesses.That puts them in an ideal position to proactively identify patients at risk of developing chronic diseases and to work closely with those patients to implement effective preventive strategies. By taking on that expanded role, PCPs should, by extension, help lower overall health care costs by forestalling hospitalizations and other costly forms of care.

For many PCPs this may be a new way of practicing medicine, getting ahead of patients’ health issues before they become costly chronic diseases. This may require some fundamental changes in how they interact with patients and manage their practices. But this burden should not rest on their shoulders alone. Government and the private sector need to rally around the transformative potential of new value-based and preventive care models and work to support PCPs in meaningful ways.

Rethinking chronic disease

To offer care that is valuable to both patients and the health care system, the sector needs to embrace a new approach to chronic diseases. Cardiovascular disease, for example, is a prime candidate for this approach. About 20 million Americans have coronary artery disease, the most common type of heart disease, and 805,000 people suffer heart attacks each year, costing $229 billion in direct medical spending, according to the Centers for Disease Control.

PCPs can not only help patients with cardiovascular disease to prevent their disease from progressing, they can also coordinate with cardiologists to manage rehabilitation programs for patients who suffer heart attacks or who require surgery. That can shorten hospital stays and prevent hospital readmissions, which is good for both patients and the health care system. Studies have shown that providing heart patients with supportive clinical programs that shifts cardiovascular care out of hospitals could result in up to 30% in savings to the health care system.

Kidney disease is another example of a chronic condition where the care model is ripe for transformative change. PCPs can work closely with patients who have early kidney disease to promote lifestyle and dietary changes and adherence to medication regimens, which can prevent patients from progressing to the point where they need dialysis. Studies have shown that a more active approach to this type of preventive care can reduce the rate of unplanned dialysis starts, as well as dramatically reduce hospital visits and in-patient utilization rates among patients with chronic kidney disease.

Finally, integrating behavioral health services into primary care practices can add value. Many practices already screen patients for depression. But some have gone a step further, adding mental health providers to their staff, integrating care models and co-managing patients with depression, anxiety or substance-abuse disorders. In 2021, the Bipartisan Policy Center estimated that integrating behavioral health services into primary care would save the system $4.7 billion over 10 years. The U.S. Department of Health and Human Services is testing payment models to support behavioral health integration with primary care.

Embracing data and technology to enable integrated care

For PCPs to shift to a whole-person approach to care, new technology solutions need to play a major role. For example, electronic health records (EHRs) now offer decision-support functions and chronic-care management tools that can help physicians select treatments and monitor outcomes in patients with chronic diseases.

The problem is, doctors often complain about the amount of time it takes to fill in charts electronically, and many struggle with the technical nature of using EHRs. EHR manufacturers should take on more of a services role to help solve these issues. They need to listen to doctors and listen to the administrators, take that feedback, and use it to help physicians get the most out of their EHR systems.

More broadly, health care and technology companies need to continue working to develop tailored solutions that leverage data and streamline workflows for providers who are regularly dealing with high patient volumes. Government can help by establishing national safety and quality metrics to support physician data infrastructure. It can also support and incentivize the use of emerging digital solutions, such as telehealth and remote patient monitoring tools, that enable preventive care by making it easier for PCPs and other providers to collaborate.

With the rise of value-based models, we are entering a new phase in health care in which our methods for preventing and treating chronic disease are likely to shift significantly. The hope is that this shift will not only reduce health care costs, but it will also strengthen relationships between patients and their doctors. The direct cost of care is largely dependent on payers who will need to provide financial incentives for pay-for-performance models.

Ultimately, though, addressing the bigger picture of reimagining the way we approach primary care in the U.S. can have a far more profound impact on costs and how we evaluate our system over the long term.

But it is a delicate balance: If we require physicians to become too preoccupied with technology, patients may feel their providers are not focusing enough on their needs. We must be careful that in the search for value, we are not moving further away from the patient. That is why change cannot come from PCPs alone but will require alignment around a new vision and thoughtful, deliberate collaboration among everyone working to improve the health of our society.

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