There is a common equation used to show health care value: Value equals quality plus patient experience divided by cost.
Despite the relative simplicity of that formula, there is still confusion over what constitutes value-based care, said Adnan Munkarah, MD, president of the care delivery system and chief clinical officer at Henry Ford Health.
One misconception is that value-based care is mostly concerned with primary care. But since specialty care is a significant driver of higher costs, it must also be a focus of value-based care, said Dr. Munkarah, who chairs the AMA Integrated Physician Practice Section Governing Council.
Another misconception is that value-based care is all about cutting costs. Value-based care interventions, however, may actually result in higher costs because of investments to improve patient outcomes and patient experience.
Nevertheless, one thing is certain, Dr. Munkarah said, health care’s problems won’t be solved by “pointing fingers.”
“How can we make sure our health care system is sustainable for generations to come?” he asked. “Because the way it is today, I don't think any one of us think this is sustainable going forward.”
Dr. Munkarah’s remarks came as he served as moderator during an education session on developing successful models for value-based care during the 2023 AMA Annual Meeting in Chicago.
The underlying principle of value-based care is managing to lower cost of care for a population of patients, while striving to improve outcomes. During the session, real-world examples were highlighted by representatives of Sanford Health and Ochsner Health.
Henry Ford, Sanford and Ochsner are all members of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Sanford’s huge rural coverage area spans some 250,000 square miles, which creates its share of challenges. Among these is that 20% of the U.S. population lives in rural areas, but only 10% of U.S. physicians practice in these regions. But the integrated health system’s relatively small health plan, which includes about 200,000 covered lives, offers opportunities to pilot value-based care concepts and models.
“It’s our petri dish where we look at is it going to work, is it not going to work?” explained Luis Garcia, MD, president of Sanford Health Clinical Division.
Dr. Garcia described how his organization used augmented intelligence (AI)—often called artificial intelligence—and machine learning to identify high users of care.
They were not surprised to learn that this population included patients with complex conditions who often faced obstacles to accessing care that were influenced by social determinants of health.
Sanford then mobilized its health guides team to help coordinate care for these patients.
“If they needed transportation, we provided the transportation, if they needed internet access, we helped them with that, if they needed help with canceling their appointments and rescheduling, we helped with that,” Dr. Garcia said.
Within the first six months of deploying this program, there was a 62% drop in emergency department visits among this population, plus a 67% reduction in hospital admissions and a 34% drop in missed appointments, Dr. Garcia said.
Similarly, Sanford ran a pharmacogenomics pilot to see whether patients being treated with one of the six types of selective serotonin reuptake inhibitors (SSRIs) were getting the right one.
Tests showed that 87% were receiving the right one. Adjustments were made and that share was boosted to 91%.
“You may say, ‘4%? Big deal,’ right?” Dr. Garcia said. “Well, it can be a big deal if you can scale this model to the 40 million Americans who, right now, are on SSRI medications, because 4% is more than a million people.”
There are also social and economic impacts of not treating depression or anxiety the proper way, he added.
Ochsner Health Network Chief Medical Officer Sidney "Beau" Raymond, MD, told how patients enrolled in a digital medicine program received a blood-pressure cuff and were sending data back to the system that was reviewed by a pharmacist who used the data to adjust patients’ medication.
Overall, costs went down, Dr. Raymond said. But not initially, particularly among patients with diabetes.
“It went up because we were getting them on the right drugs,” he said, noting in particular the importance of getting patients on sodium-glucose co-transporter inhibitors. “But we know later on, outcomes are much better, so it is the right thing to do.”
In all, Dr. Raymond said Ochsner has more than half a million lives covered by value-based care agreements, with about 150,000 of those patients covered by Medicare or Medicare Advantage.
“Why would we do this?” he said. “Because in the fee-for-service world, it's geared toward transactions. So the more you do, the more you get paid.
“Outcomes are not actually that relevant, so it's just about churning,” Dr. Raymond added. “That's not where we want to be.”
Through automation and care coordinators, Ochsner works to take routine tasks off the primary care physician’s plate.
“We want primary care physicians to focus on the patient in front of them,” Dr. Raymond said.
Another focus has been on home-based care, particularly after discharge from the hospital.
The goal is to “keep them healthier and keep them at home where they want to be,” Dr. Raymond explained. “This may shock you, but patients don’t want to be in the hospital.”