Sumit Bhardwaj, Executive Vice President, CitiusTech explains how adoption of value-based healthcare is enabling a paradigm-shifting transformation of the healthcare system
Today, ‘value’ is at the heart of every aspect of human need. This notion doesn’t change for medical care, despite it being an essential need. And with time, healthcare is transitioning from a fee-for-service (FFS) model, (that is ‘one-time’ in nature) towards a more comprehensive and patient-centered approach of value-based healthcare (VBHC).
This shift is gaining rapid momentum, so much so that VBHC as a market was valued at $6.07 billion in 2022 and is predicted to reach $32.69 billion by the year 2031. The wider deployment of this model is being effectuated by the varying needs of the different stakeholders in the healthcare continuum – providers, payers, and policymakers. This is also a sign that all these parties are placing the most important member of this system at heart: the patient.
Shaping a patient-centric healthcare ecosystem
Today, around 44 per cent of service providers and 23 per cent of payers have reported that their top priority has been the improvement of health and wellness of their targeted population. This simply goes to show that the adoption of VBHC is enabling a paradigm-shifting transformation of the healthcare system.
Transitioning from clinical outcomes to patient outcomes
Conventionally, the outcomes experienced by patients after a treatment or medical procedure are observed from a clinical standpoint, where it is focused on the ‘before and after.’ For instance, the improvement in an individual’s condition after undergoing a knee replacement surgery would be gauged based on the pain and difficulty in movement. With a value-based approach, however, the emphasis is shed on knowing if there is a greater range of motion and functionality that betters overall health.
Cohesion between various stakeholders to deliver more value
A thorough transition from FFS to VBHC is possible only if there is increased collaboration between the various stakeholders. Whether it is the healthcare providers or payers, insurers, and policymakers/ regulators, all are functioning more closer than ever to offer the most value to their patients. By incentivising, sharing knowledge, and leveraging technology amidst other measures, healthcare institutions are instilling more emphasis on patient-centered care.
Evolving from generic therapies to specialised care
The healthcare landscape is evolving away from a ‘one-size-fits-all’ model, thanks to the principles of VBHC. Instead, we’re witnessing a shift towards tailored patient care with personalised treatment plans and precision medicine becoming increasingly prevalent. Crucially, subspecialists like oncologists, cardiologists and neurologists, among several others are now more accessible to patients. For instance, if a patient exhibits symptoms of renal disease, the growing flexibility of the VBHC framework enables direct access to a nephrologist rather than taking a long generalist-to-specialist route.
Enhancing the delivery of value
Offering value to patients involves a complex interaction of a variety of elements that encompass the metrics employed for value assessment and the challenges associated with their implementation. Regardless, achieving synergy among these elements can help improve the quality of healthcare delivery. Here are the metrics that can help in evaluating value:
- Safety of care: Models to measure patient safety are integrated into VBHC. This includes treating the prevention of secondary infections, preventable hospitalisations, and related factors as key quality measures. According to the WHO, 80 per cent of all primary and outpatient adverse events are preventable. Hence, safety is a key metric.
- Readmissions: The duration of readmittance following hospitalisation is a critical outcome measure. An example of this metric in action is the provision in CMS’ Readmissions Reduction Program (HRRP), where hospitals are penalised if their readmission rates of patients within 30 days of discharge are high.
- Patient experience: Patient-reported outcome measures (PROMs) are an important metric to ascertain whether specific treatments have enhanced patients’ quality of life. CMS lays emphasis on the measurement of PROMs to reward the performance of healthcare providers and physicians for improving outcomes for patients.
- Timeliness and access: Ensuring that patients receive timely care and reducing the number of barriers that delay the provision of treatment is another vital quality metric. From shortened wait times to ease of booking appointments, measures to fulfill the preventive aspects of VBHC are essential.
Due to the intricate and interconnected nature of the VBHC framework, the aforementioned metrics have a ripple effect on other indicators such as mortality, cost and resource utilisation, and effectiveness of care, among others.
Challenges surrounding VBHC
The metrics implemented in the healthcare system also bring along their own unique set of challenges, and this notably has a significant impact on contract management. A few of these challenges include:
Absence of standardisation
Several of the metrics in place measure aspects of care that are similar. Yet, they utilise benchmarks and scoring methodologies that are varied. This can give rise to an excess of data and complications in its interpretation. For example, providers associated with VBC program contracts will view identical metrics applied to different sets of populations and payers along with different benchmarks and methodologies. This can complicate the evaluation of metrics in terms of commercial versus government programs.
Complicated measurement systems
The complex measuring systems–marked by different benchmarking scales, percentage schedules, and point systems–make the achievement of commonality difficult and make the process of tracking and auditing metrics challenging. This also affects the healthcare providers’ ability to identify areas, both financially and clinically, that require refining, thereby affecting contracts.
Gap between clinical and financial outcomes
The various stakeholders of VBHC, more than often, are proficient at either measuring financial results or clinical performance at a metric level. Unfortunately, there is no balance between the two. This makes it difficult to link contracts’ financial results with the actual clinical outcomes. As a result, the alignment between the various parties is impeded.
Strategies streamlining the VBHC Ecosystem
Just like any intricate system, VBHC is evolving and growing at a continuous pace. The stakeholders involved in the care continuum are constantly in a state of learning, fine-tuning their procedures and ultimately shaping the overall ecosystem. Here are some strategies at play to better streamline the VBHC ecosystem:
Identify high-risk patients
The purpose of VBHC is defeated if high-risk patients are not identified and provided timely care. Data on these populations can be gathered through annual doctor visits, self-reporting of wellness on online portals, and other methods. With the help of a healthcare data platform, the data can be transformed into actionable insights that can help detect high-risk populations and suggest beneficial interventions. This includes new treatment plans, referrals to specialty care, and wellness programs, among others.
Addressing gaps in the delivery of care
Unlike FFS, where care is ‘episodic,’ VBHC provides greater scope for addressing overall patient outcomes. In the case of patients who seek regular check-ups or follow-ups, it is easier to spot and address the gaps in care. On the other hand, for patients who approach healthcare professionals only in the event of acute illness or injury, this process is challenging. Nevertheless, such visits can be turned into opportunities to bridge the care gap. From verifying pending preventive care options to scheduling screenings, there is much that can be accomplished.
Communication between stakeholders
The interdependent nature of VBHC demands better communication between various stakeholders. From providers to payers and members within a network, transparent communication can save both time and costs. For example, communication between care providers in the same network can help prevent overlaps, or staying in touch with provider relations representatives can provide physicians and hospitals with updates on their scoring systems and changes in incentivisation.
Secure sharing of data
The availability of patient data with the assurance of privacy can maximise patient outcomes. For example, access to patient data between various stakeholders in the VBHC network can ensure that a patient receives specialised and customised care and services on demand.
Instilling value at every checkpoint
The transition of the healthcare ecosystem towards VBHC represents a transformative approach that prioritises the health and contentment of the patients. While the road to its complete fruition is engulfed in some challenges, it continues to evolve and refine further. As various stakeholders collaborate to advance patient-centered care, it is clear that the future of healthcare is undeniably oriented toward value-based principles.
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