- While value-based care models have made great strides toward breaking down silos, coordinating care, and better serving patients, it is time to take steps further.
In order to make value-based care truly beneficial to patients, those very patients have to be at the center of care, according to experts presenting at Xtelligent Healthcare Media’s third annual Value-Based Care Summit.
Based in the premise that value-based care is inherently beneficial to patients, experts from Steward Healthcare, UMass Memorial Accountable Care Organization (UMMACO), and the New England Quality Care Alliance (NEQCA) discussed where value-based care is currently, and where it needs to go in the future.
“When I think about the value these care models bring to patients, I really think about the actual goals of accountable care and value-based care, which have to do with clinical integration and visibility across the continuum of care,” said Deborah Yolin, PA-C, the associate medical director at Steward Healthcare. “What that does is set patients up for wrap around services.”
Value-based care models make continuity of care possible, Yolin explained. A Medicare patient can be discharged from a hospital stay into a skilled nursing facility. Care manager nurses can communicate with the patient, uncover care goals, and discuss those goals with the rest of the patient’s care team. This ensures care is patient-centered, efficient, and satisfactory.
John Greenwood, the president of UMMACO and UMass Memorial Population Health division, agreed. And when organizations focus on those value-based care goals, the money fills in around it, he added, referencing his experience as a chief financial officer.
“This brings sustainability to these programs so they can help the patient through the system and really be able to provide that what I call consumer experience,” Greenwood said. “How do we provide services that patients otherwise wouldn't have the access to?”
Healthcare organizations are primarily working to keep the patient healthy, said the panelists, which also included Jatin Dave, MD, MPH, chief medical officer of the New England Quality Care Alliance.
This means focusing on wellness, turning to services outside of the facility that assist patients in achieving health, and paying for services that an organization might not normally pay for, Greenwood said. Nutritional food programs, transportation services, and connecting patients to affordable housing are all key areas of value-based care that are beneficial to patient health.
Integrating all areas of health, both clinical and societal, is exactly what value-based care is about, Yolin added. By nature, the concept of value-based care is ideal for patients because it breaks down the silos and the fragmented care that often does lead to sub-optimal outcomes, she said.
But as organizations continue to embrace these care models, there is a key voice that is being left behind, Dave and the rest of the panelists pointed out.
“Value-based healthcare has to help the end user, the patient, the way usual purchasing works. It is complex in the healthcare system, but it has to help the patients,” Dave said. “It is not easy to do so. We have made it more complex than it should be. But ultimately the consumer to an extent does have the buying power to elect for the most part what they will consume.”
This means organizations need to put patients at the center of their value-based care models, Yolin, Greenwood, and Dave agreed. But how can we do this?
To start, industry leaders and organizations can approach the question of value another way, Greenwood said.
“The issue is not so much how we define value because there is probably a lot of fragmentation in perspectives,” Greenwood explained. “Instead it's really how the consumer defines it going forward.”
Dave agreed, saying the industry needs to ask the patient what they need to refine approaches to value-based care.
“We are trying to pretend to be a consumer to an extent but it's still not a perfect match,” Dave asserted. “At some point in time we need to go to our consumers and ask what they think of the entire system.”
This requires a sense of understanding how patients currently interact with value-based care models. For Greenwood, that means looking at how well the programs are currently working.
“When you take a look at those quality indicators and you watch them and see what they're doing, that gives you a gauge on how well we might be or might not be connecting,” Greenwood said.
If a value-based care model is not fully developed for the patient and is not yielding patient engagement with care, care outcomes will likely be poor.
Yolin also looks at dropout rates.
“We identify patients who were enrolled in a program and dropped out or patients who declined ACO care,” she explained. “Then we'll go and actually talk to care managers we'll listen in on phone calls. We try and make sure that they're providing the highest-quality telephonic or even face-to-face services out in the community and try and see if we can see a pattern.”
Conversely, looking at patients who have enrolled in or completed their value-based programs help identify a list of best practices for engaging patients, Yolin added.
Yolin, Greenwood, and Dave are finding that patients are not yet involved enough in these programs. For one thing, patients don’t even usually know they are receiving care as a part of an ACO or another value-based care model.
“We've brought that up to CMS and to others as well,” Greenwood said. “Where's the patient? We're focused on the patient but where's the patient for your perspective and how are you educating them or not?”
A lack of patient education about value-based care is leaving patients ill-equipped for fully engaging with the system, Greenwood, Yolin, and Dave agreed.
CMS does have some materials to help improve patient education about value-based care, Yolin explained. When they formed their ACO at Steward, CMS provided Steward’s facilities with letters for patients explaining the pillars of an ACO and how they can improve their health when receiving value-based care.
“How many of those end up in the trash?” Yolin said, noting that providers at her practice have to fill in the blanks. “We really help them understand why staying in network is so important with visibility into their care, for example.”
At UMMACO, providers extend this education to family members as well, noting that family engagement is key for patient activation in care.
“Helping both of them understand that being part of this program, especially if you have complex needs, if we're getting you regular sessions with your physician or a specialist or whatever you need, this is going to try to keep you out of the emergency department and becoming an inpatient,” Greenwood explained.
But it’s these very patient outreach strategies that must integrate the patient, Dave posited. The way one patient wants to be engaged in her ACO is not necessarily how providers should reach out to another.
For example, younger generations are looking for an Amazon experience. They don’t necessarily need a primary care provider, Dave said, but more of a doctor on demand who can tend to acute needs as they crop up. Technology can fuel patient outreach here, and might be set to change healthcare forever.
Those differences in patient preferences is a significant part of the challenge, Greenwood and Yolin said.
“I think all of us who are healthcare professionals don't recognize how challenging that is because we're dealing with patients who want phone calls and patients who want text messages,” Greenwood said. “We do have to understand that people want be communicated in different ways. That's a little bit of the challenge right now because we're across the whole spectrum.”
That’s not to mention entire populations who aren’t necessarily reachable, Yolin added.
“There's a whole population that you cannot reach, they're either discharged to their car, they don't have phones, they're out of minutes,” she said, referencing low-income patients or those experiencing homelessness. “That has posed a whole new philosophy and challenge on how we manage that group of patients in terms of setting up a very different type of behavioral health chronic complex type of a program.”
Confronting these challenges has required organizations to address the social determinants of health, defined as the lifestyle factors that influence a patient’s ability to be healthy.
“This awareness has completely shifted how we deliver care, and what our care models are,” Yolin said. “We now employ community health workers and social workers and actually we're working on licensed independent substance use disorder clinicians. They're out in the community, they're embedded in practices, and they really work in more of a care coordination role.”
ACOs are also setting up new social services, including housing stability teams and behavioral health referral lines.
Additionally, organizations work on data collection and dissemination. This information helps providers do their jobs as clinicians as well as set patients up with necessary social supports.
But again, this new focus on the social determinants of health points to the larger issue that not enough of value-based care puts the patient first, Dave said.
“We have very limited social funding compared to medical funding,” he asserted. “We spend a lot more on medical needs so we can assess all we want to. But now we don't have enough ways to fill the gaps.”
There are advancements on the horizon, of course. More hospitals have come to understand their roles as community leaders, and new policies are putting behavioral health and the social determinants of health at the forefront.
But as organizations begin to integrate patients into the value-based care puzzle, they must do so together.
Disruption can be helpful, but if organizations do so in their own ways, it could lead to further fragmentation, putting the patient at risk. Moving forward together as an industry will be essential to ensuring value-based care is truly beneficial to the patient.
“Everybody says they want to fix healthcare, but everybody wants to fix it in their own different way,” Greenwood concluded. “I really think as healthcare professionals, we have to solve the challenge of patient-centered care at some point. That could be through data or just more cohesiveness and how we work. If we focus solely on the patient and then build sustainable programs, I think we'll get there.”