This is another idea in the effort to improve healthcare that is gaining momentum (slowly) but is a little fuzzy in people’s minds. In this case, both the concept and the execution are tricky. I mean, “value-based care”? It sounds like a business term that uses words that mean something specific to describe something those words don’t mean, which just sows confusion. (If a core competency is supposed to mean a fundamental strength, why do they use a word, competency, which means mediocre?)
Value-based care does have a definition, although that definition is different depending on where you look. Some mention elements like patient input, patient satisfaction, lower costs, and better outcomes. What it comes down to is an overall delivery model where you achieve better health outcomes for the cost of care. Right now, change in this area is being driven by government regulation and programs. The Centers for Medicare and Medicaid Services is looking for models that include higher levels of patient participation, and therefore patient satisfaction and measure outcomes through “relevant medical results”.
Sounds great, right? Right. But there are a few hurdles standing in the way.
First, you have to get providers to incorporate the patient input. Right now, there is a small cadre that do this, but it is viewed as a revolutionary approach, and depends wholly on the evolution of the provider’s experience. Whole person treatment is not part of the infrastructure -- no aspect of patient-centered care as part of clinical practice is standard curriculum in medical schools.
Second, evaluation of what constitutes “value” is based on “relevant clinical results”. What does that mean? Who decides what is relevant? Are they talking about improved disease markers like lab tests? I can give you examples as to why lab tests are a fallible measure: the A1c, which measures average blood sugars over three months, is heavily weighted toward the last four weeks, and as an average, can display a positive result even if a patient is bouncing from extreme highs to extreme lows. An A1c of 6.5 is a great and relevant clinical result, but if a patient gets there by swinging between 50 and 250, that is not as great.
Third, patient satisfaction is a subjective measure. The state of a patient’s condition may improve, but without knowing the patient’s goals, which can differ from the provider’s, it can mean a more restricted life, and that may adversely affect a patient’s satisfaction. A personality mismatch between patient and provider can also produce an inaccurate reflection of positive outcomes. And if the patient is struggling with their mental health, and that is causing self-destructive behavior, the provider can be doing everything right, and both “relevant clinical measures” and patient satisfaction are going to take a hit.
The government has been moving in a value-based care direction for a long time, since before the Affordable Care Act passed. In all that time, I can find no posted official definition, nor matrices for evaluation. I found one article from the National Institutes of Health, but no policy. This illustrates just how hard a concept value-based care is to get your arms around. It might fall into the herding cats category. As someone who has spent most of her career on federal agency policy, I sympathize. I really do. All I can say is that whatever they come to, I sure hope they have patient perspective incorporated into the final product. Otherwise, value-based care isn’t going to be as valuable as it could be.