At last year’s HIMSS22 in Orlando, Fla., the Digital Medicine Society (DiMe) and the Veterans Health Administration (VHA) launched a value-driven framework for evaluating healthcare innovations. In a recent interview with Healthcare Innovation, Cole Zanetti, D.O., M.P.H., the acting director for value-based care in the VHA’s Center for Care and Payment Innovation (CCPI) and a senior advisor to the VHA Innovation Ecosystem, discussed how the framework is being applied at the VA.
HCI: First, what is the mission of the Center for Care and Payment Innovation?
Zanetti: Its focus is to test and pilot new care and payment innovation models within the VA, which is the largest integrated healthcare system in the United States and is dramatically different than the private sector. One of the fundamental tools that the Center has at its disposal to facilitate this is its waiver authority. This allows VA to ask Congress to waive certain statutes governing VA related to hospital, nursing home, domiciliary, and medical care so we can pilot new care and payment innovations. We can also request exemptions to policies within the VA to allow us to test new opportunities that current policies or directives may restrict.
As an example, if there is a Veteran in a rural setting who is struggling with rheumatologic issues and there aren’t many of rheumatologists in that location, the VA could allow any physician who is working at the VA to provide this Veteran with care from anywhere in the country. That's not actually happening as often as you might think because of the way workload is captured and how funds are distributed within the VA. CCPI is beginning to look at data to better understand these types of opportunities for resource sharing and identify ways that we can help to restructure the system and continue to move the VA towards a value-based health care system.
In other parts of the healthcare system, when they use the phrase value-based care, usually what people are referring to is population health approaches and capitated payments rather than fee for service. How does that definition fit with what is happening in the VA?
Zanetti: We're fortunate in the VA because we don’t have the same restrictions as the private sector. For instance, we have a program where community workers provide outreach to help Veterans who are struggling with suicidal ideation. There isn't an ICD-10 code associated with that kind of activity, but we do it anyway because it's the right thing to do. Unlike private health systems, we get funded directly from the government, which means we can look across our system to identify where funding can be distributed to have the most meaningful impact on health. This is how we can invest in value-based programs like the one that supports Veterans struggling with suicidal ideation.
We also look at what is within the control of a healthcare team. I'll give you the most classic example. I'm a family doctor. Sometimes we will get a notice that a diabetes blood test, a HA1C, was not completed for a patient, but we look in the record and see that we ordered the lab work for that patient. We also reached out to that patient and scheduled time for the lab work, but the patient didn't attend the appointment. So, we get our social worker involved to figure out how to best support that person. We're doing everything that we can to help the patient, but because they didn't get that lab done, we still “failed.” By using a value-based care approach, we can measure all evidence-based work the healthcare team is doing to care for the patient while understanding and accounting for factors that are outside of their control. We need to make sure that the outcome or process measures assigned to a team, or an individual are evidence-based and within their control so we are asking healthcare teams to do things that are necessary and realistic.
Is part of your center’s work to better align those things and to look at the VA and see which kinds of things are providing the most value and to scale them up across the system?
Zanetti: Absolutely. I can give you a great example of how we do this. VA has worked in collaboration with something called the remote temperature monitoring system, which uses remote technology to tell us if someone with diabetes is likely to develop a diabetic foot ulcer. We've used this in multiple VA settings, and it has helped reduce limb amputations for Veterans. Ultimately, this means fewer Veterans are coming in to see physicians and there are fewer complicated health events occurring because the system works so well. But, fee-for-service funding systems could dictate that the facilities participating in this program actually need less funding because there are fewer patient encounters – without accounting for the resources needed to sustain this program or the fact that we actually improved the Veterans’ health, which is our goal.
Our job at CCPI is to say there's a misalignment between what we know is right, in terms of health outcomes, and what we're measuring and therefore funding. In this instance, we are working to reconcile that misalignment by using time-driven, activity-based costing, where we are looking at our health outcomes and determining what is needed for scalability. We also look at how the system could be impacting health equity and access for Veterans who could leverage this technology. We then provide a recommendation to VA and potentially Congress on how to modify the system so that this value-based care solution can grow. Whether it’s the remote temperature monitoring system or another care delivery model, CCPI is always asking if there are meaningful improvements in health outcomes that are having a difficult time scaling because of system affects. We're working through how to remove those obstacles, test and iterate to define a new system that incentivizes those actions, and then scale it across the country.
And is that tied into the work that your team is doing with the Digital Medicine Society on a framework around identifying that kind of value?
Our organization has worked with DiME on establishing a framework and principles to guide value-driven innovation, which touches on access, effectiveness, efficiency, equity, meaningfulness, appropriateness of scale, and time to value realization. It’s a critical tool in helping CCPI and VA to measure the value and impact of new healthcare innovations. Within that framework, we've also defined each category in greater, data-driven detail, so that when we're evaluating opportunities to test or scale projects, to ensure that we're using a consistent lens.
Could other large health systems use the same kind of framework about measuring the value of an innovation or do they have more restrictions in terms of the way things are paid for?
Zanetti: When you look at major health systems, most of them have a mix of different payers. You have some at-risk contracting, you have fee-for-service contracting, you might have some global payment contracting—it’s a mixed bag. Sometimes you could even have multiple different payers within a single market. And it's changing all the time. Most of these different entities also have their own quality measures that are different from each other. My mind was blown the first time I learned there were four different ways that you could measure hypertension as a quality marker! That's an obvious struggle that the private sector continues to have.
Part of the reason why I came to the VA from the private sector, beyond feeling honored to have the privilege to care for our nations Veterans, is that I thought that the VA can serve as a beacon of what care and payment models should be for CMS and the private sector. The VA has an amazing opportunity and flexibility to do this. That's why the VA was a leader in telemedicine well before the COVID pandemic. What we can effectively demonstrate could be a part of conversations on what changes should happen in the private sector. We're achieving the outcomes and measuring the things that matter critically to our Veterans and achieving the cost avoidance that is necessary for long-term sustainability.
