Value-based care: Whose value?
“…and her glucose is normal so she is ready for discharge,” I exclaimed with pride.
“What about her potassium? Did you notice that it is 6.0 this morning?” the attending asked.
“Uhhh…the specimen was hemolyzed, so we can ignore that,” I replied.
“We can’t ignore it. Repeat it in three hours; if it’s normal, discharge her. In the meantime, get an EKG,” the attending ordered, adding, “Why did you order a potassium today anyway?”
“It comes as part of the standard panel.”
“Well, not only did you order too many labs—we could have used a fingerstick glucose—but your over-ordering led to additional labs, an EKG, and a major inconvenience for the patient. Keep the value—to us and to the patient—of every test in mind before you order it,” the attending concluded.
My attending that morning taught me a valuable lesson about understanding the impact of my decisions beyond what was in my line of sight. As medical students and young physicians in training, we learned—sometimes at great pains to our egos—to proceed efficiently and effectively to improve the health of our patients. From life-saving interventions, to acts of prevention, we learned to deliver value to our patients regardless of how or where they presented to us. So, when we hear people—often nonclinicians—talk about value and value-based care, we physicians frequently react with confusion and defensiveness. We know value.
Or do we? Are we closer to my medical student persona in the anecdote above than we realize? From the perspective of patients (especially future patients), payors (including employers and the federal and state governments), and health plans, value carries different meanings. To a patient, value can mean outcomes—“Will I get back to my previous level of function? What should I be doing now to have more enjoyable older years than I see my parents having? How much is this treatment going to cost?”
To a payor, value can mean, “How much will I be spending on my employees? What health and productivity improvements can I expect for that expense?”
And to a health plan, value can mean, “What care is being delivered, what outcomes can I expect, and what will the experience of care be?”
When the value perspective is broadened, we can see that what counts toward value-based care goes beyond the exam room, hospital bed, or surgical suite. To achieve true value-based care and value-based payment models, we need to bring the full view of value to each perspective and align incentives to achieve value from everyone’s perspective.
The necessary and achievable tool for driving our healthcare system toward value is actionable insight. Actionable insight requires data and appropriate, relevant analysis of that data. Data needs to come from the clinical record (usually the electronic health record), administrative sources (for example, medical and pharmacy claims), and consumer sources (such as wearable information and purchasing habits). Such a broad spectrum of data requires full interoperability—data that can be sent, received, and used without further transformation.
Furthermore, actionable insight requires analysis of data and delivery of information to the right person, at a moment of influence or decision-making. Such analytics need to be performed as close to real time as possible and in a trusted, transparent way. Decision-makers need to have full visibility into the analytics upon which they rely.
Imagine, for example, a slightly more complex version of the encounter with the attending recounted above. If, on admission, a clinician has access to a complete patient profile, based on all available, relevant information (including medical information found in the claims record and from wearable devices), would that enhance the patient’s experience of care, clinician’s ability to deliver more precise and timely care, and perhaps lead to improved outcomes? If, in addition to a complete patient profile, the clinician had access to insights derived from an analytics engine running in the background providing differential diagnosis possibilities and appropriate lab and other testing suggestions, would the patient, physician, and payor derive greater value? Rather than a fragmented, incomplete, and retrospective review of relevant information, such a system would deliver timely insights at the moment of decision-making, supporting—rather than interfering with—the clinician and patient encounter.
Such a system might sound farfetched, but elements of it are already in place in many healthcare systems. And studies have shown that electronic decision support helps increase rates of preventive care (for example, using electronic reminders for preventive screenings and immunizations increases the number of patients receiving those services.)
Value is what we all seek in our healthcare system, but, in our current system, value is derived and measured in different (sometimes conflicting) ways by different participants in the system. We need to understand and align these perspectives, using data and analytics in ways that support everyone’s interests, to achieve the full value-based healthcare system we all seek and deserve.
