Value-Based Health Care — a 5-sided coin?
by Verena Voelter, MD and Caitlin Masters, MPH,
upon invitation by the THINKERS MAGAZINE at the Value-Based Healthcare Center Europe, Winter’s 2023 edition
We are putting a different spin on Value-Based Health Care (VBHC). Much has been written about it and a slew of new books flood our virtual bookshelves every week. This is a good thing! We need a massive revolution to undertake the seismic shift away from paying for the wrong incentives, putting patient outcomes and health care worker burnout consistently on the sidelines. This article is about walking the talk and making VBHC real.
1. The 2-sided Coin: What Works and What Doesn’t
Talking about patient outcomes and physician satisfaction does not mean we can’t talk about money. Indeed, this article is all about the money. And it is all not about the money at the same time.
Let’s discuss, step by step.
As eluded to, our current legacy health care system is built on Fee-For-Service (FFS) — you produce more surgeries, you sell more pills, you see more patients per time unit — and you’ll earn more money. As simple as that. Did you see an incentive to look after the quality of the procedure delivered? Did you see a notion of listening to and addressing what the patient needs? No. Today, the incentive is volume. And more volume logically leads to higher compensation. The FFS system disconnects health care and the desired outcomes from its ultimate customer, the patient, with its desired health outcomes. The FFS system is a deadend! The funds of our health care budgets are not infinite. And that’s what we read in our daily headlines: bad pharma producing super expensive drugs, greedy payers not reimbursing them. Just to cite a couple. The list can go on.
The solution is to flip this system upside-down, i.e. VBHC: rewarding and paying for outcomes. Compared to almost 20 years ago when Michael Porter and Elizabeth Teisberg first published the groundbreaking principle that VBHC = Outcomes / Cost, in this day & age of data at our fingertips, we now have the means to scale this principle. Electronic data capture through the EMR & artificial intelligence (AI) allow for mass processing of relevant data along the patient journey over time and the ability to share this data with everyone in the care coordination team who needs access to it.
The magic word here being coordination. Many actors & activities need to be coordinated to satisfy a patient need & problem as outlined in our Breakout box below. This does not only involve doctors & nurses, but increasingly so, social workers, physiotherapists, mental health coaches, midwives, nutritionists, data analysts, care coordinators, medical coders, and the list goes on when we consider the social determinants of health (SDOH) which determine more than 80% of our health outcomes. And not procedures, pills, and visits at the doctors.
In short, health care is like a 2-sided coin: one has delivered phenomenal progress in medicine and longevity; the other has broken our health care systems because it disconnected from its ultimate customer, the patient, with actors along the patient value chain working in silos.
2. Value-Based Care is Negotiation
If you think about the phenomenal progress in medicine eluded to above, this is not the result of one group alone. It is attributed to the seamless collaboration between many researchers, clinicians, visionaries, investors and patients working hand-in-glove in a virtuous circle: patients receiving care, providers providing care, pharma developing care, payers paying for care, and policymakers delivering the frameworks. This ‘5P’ ecosystem has delivered many successes. One of which has been the recent development of more than four Covid-19 vaccines in less than 12 months. Sharing interests and risks, rewards, and benefits — this is what the optimal 5P coordination can deliver as seen in the Covid-19 example.
Referred to elsewhere as public-private partnerships, novel models involving academia, governments, large scale associations like the WHO and other consortia across borders are capable of delivering tailored solutions at maximum efficiency. Of course, health care is not a fairy tale. This doesn’t happen without friction. Too much bargaining power is at stake and too much money globally in the system. In the US alone, in 2020 over 4 trillion (!) US dollars are circulating in the US healthcare system. No one wants to forfeit their shares of that pie.
How to solve this quandary in real life? By focusing on the common purpose. Just like by going back to the Covid-19 example. In this case, the common house was on fire: saving lives, quickly. Everyone instantly knew: you need the pharmaceutical industry to develop a vaccine at scale, you need governments to ascertain the upfront investment and early procurement of secured doses, you need academia to drive target identification and patient registries to learn about this novel disease.
Outside of a vital crisis, it comes down to leaders to create this sense of urgency within their scope of responsibility.
However, there is no one defined leader or decision maker — just like with the 5Ps that don’t have one conductor — the secret to success is threefold:
a) leadership,
b) common purpose, and
c) a playbook to orchestrate the diverging interests across the 5P.
We already discussed the first two and now to the third. It relates to a joint playbook that can assist leaders from opposing ends of the health care spectrum — such as it happens daily at the negotiation table between payers, pharma, policymakers, providers, patients. Without stretching the scope of this short article, this framework is referred to as the 7 steps of Multi-Party Collaboration and serves a perfect song sheet that can help the 5P actors to orchestrate their interests to achieve the common goal of improving outcomes for patients in a new Value-Based Health Care system. As showcased in the personal story in the Breakout box, you can realize how the joint focus on outcomes galvanizes teamwork.
In health care, there are not only 2 sides to a coin. There are 5 sides that need to coordinate to deliver true value for all actors involved.
Focusing on the common purpose, aligning interests, and forging novel relationships are what collaborator-leaders do in Value-Based Health Care of the future.
Cooperation is the future of health care. Putting the patient back at the center provides the galvanizing North Star we have disconnected from, in a FFS system that had only looked at money without looking at the customer. The good news is that this shift towards Value for All is not only the right thing to do from a patient and ethical perspective, but also leads to substantial reduction of waste through the elimination of unnecessary care ultimately leading to improved cost efficiencies, too.
3. Breakout box: The real story of a patient fortunate enough to live in a VBHC environment
Let me share with you a real, personal story. Only 4 days after giving birth to my first baby girl, I felt exhausted and discovered I had a 39°C fever. I never get sick, not with a fever! I was laying in bed at home, feeling terrified that something may have gone terribly wrong. Of course, I had no experience, it was my first child. Questions like: ‘Do I need to go to the ER? What do hours of wait there mean for the girl? Can I protect her from the germs? How will I feed her if I end up staying there?’ It was spinning in my head.
Luckily, I live in the Netherlands. As part of the Dutch insurance scheme, a maternity nurse (Kraamzorg) comes to the mom’s home for the first 7 days postpartum. After reading about it, I realized that it’s because of that benefit, that mother and baby are generally more healthy despite both being discharged only hours after giving birth. “Health and health care start and end at home” as Verena Voelter writes in her book “It Takes Five to Tango in Health Care”, and the Netherlands practices this. As in my case, the Kraamzorg plays a central role in the positive health outcomes of moms and babies and is at the core of the care continuum for a mother postpartum.
My worries didn’t need to last long. Within minutes, my Kraamzorg checked for key symptoms of mastitis, cystitis, or a uterus infection. As part of the care coordination team, she is on speed-dial with my midwife who in turn checks with the doctor, both had looked after me during childbirth. Only an hour after my initial worries — upon immediate recommendation by the obstetrician, and, with my husband and my baby safely at my side — I was back at the same ward, the same floor, with the same team that knew about my situation. I received the right blood exam, the right urine tests, only to confirm that I had a simultaneous infection in two organs. Rare, but that can happen, and it can be serious if not treated promptly. Lucky for me living in the Netherlands, I started my treatment for the right diagnosis at the right time.
Why is this so critically important? Not only to make me feel good because I saw familiar faces with my fears taken care of immediately. It is critical because of the right investment for the right patient population at the right time: during a very sensitive, high-risk period of time. Primary prevention, education, home care deployment of socio-economic resources, care coordination with the most relevant stakeholders, and a holistic view of mother and child. This allows to avoid under- and overcare through time lost in finding out what’s going on, an inappropriate team, duplicate tests, and an overall situation aggravating quickly, leading to even more costs and unspecific diagnostic and treatment measures.
Now, let’s take a step back. In many other places, this would mean walking into the ED, waiting for hours to be seen by unknown clinicians, hoping they have access to my records or I would have to explain my entire medical history (in worst case multiple times to multiple people), all the while my 4-day old baby is (hopefully) sleeping next to me. Instead, my journey started at home where only because something was determined acute and as a result of discussion across my care coordination team did I need to go to the hospital without delay.
Looking at the economics of this story: hours in the ER with a multiple of stakeholders involved — versus — a quick visit to the midwife and obstetrician who are familiar with the case; tailored tests of blood and urine — versus — a battery of tests (possibly radiographics, possibly unnecessary) requested by a team not specialized in obgyn; time elapsing, an aggravating clinical situation, further increasing cost, and adding on the cost for taking care of a newborn in a regular ED.
For me, the story ends well. I walk out of the hospital two hours later, carrying my antibiotics for mastitis and bladder infection, knowing that by the following morning, my Kraamzorg is back at my side. ~ Caitlin Masters
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#FFS #VBHC #PROMS #5P #OUTCOMES #PREVENTION #IOT #HOSPITALATHOME #KRAAMZORG
