‘Value’ of Care Was a Big Goal. How Did It Work Out?

A period of Medicare innovation has resulted in more “singles than home runs.”

Comments: 33

  1. It is easier to treat the metric than to treat the patient. How does this affect patient care? At one point, in my town, there were no primary care providers taking new diabetic patients. Why? What is wrong with a diabetic patient? Under the old system of fee for service, nothing. However, under a performance based system in which providers are paid for keeping their diabetic patient's blood sugars controlled, their eyes and feet regularly checked, their kidneys functioning, a couple of new, high risk, uncontrolled diabetics could completely erase all the work--and payment--that has accrued over a year. "Pay for performance" can easily become "pay for turning away sick people". It is easier to cherry pick the healthy than it is to cure the extremely unhealthy. Health insurers know this and health care providers, when faced with dwindling reimbursement, quickly learn this, too.

  2. Take a deep breath, if you can. Doesn’t that sound like it should be illegal rather than encouraged? What kind of America have we become?

  3. OK. So could The Upshot tell us how health care value in the United States compares with the same metrics in countries that have implemented universal healthcare? Instead of attempting to reinvent the healthcare wheel, tell us how we stack up against systems that cost half as much, cover everyone, have no copays, and send their students to medical school without their having to pay tuition. Isn't that the real comparison? And why won't The Upshot tell us how we do stack up against those vastly more successful systems?

  4. @Sean the debate shouldn’t be about funding model (is universal or not), it should be about how healthcare is priced. The issue is that even with these ‘value’ programmes, the hospital has little incentive to save (see article) and the market has little incentive to self optimise. What’s really needed is a price for the whole episode and that needs to be all in. Providers should have the freedom to set it, but then the market will decide what the uptake of that offer will be, alongside the ‘specification’ of what that provider wishes to include within it. This allows the market to define quality based on demand and price to balance reflect it accordingly. The value programmes to date have stopped way short of that and it therefore doesn’t create the opportunity for innovative providers to excel or even to explore the question. If we can get this piece right, alongside good primary care, much of the issues of cost in American healthcare go away without having to tinker with the funding model. (Frankly, these steps are probably required in any scenario to prevent the cost escalation getting worse)

  5. trouble with hoping the market fixes anything is that purchasers are not spending their own money. the market has not and will not correct our healthcare issues.

  6. There are several problems related to tghe lack of success: 1. Large variability of the quality of home health care. 2. Poor communication among primary care physicians, specialists, pharmacies, laboratories and home care services. For example, a family member needed a blood draw for lab tests prior to a visit with a specialist. The home nursing care agency contracted with a blood draw technician to come to our home, draw the sample and take it to a laboratory. That lab was not electronically connected to either the specialist or the primary care physician. The lab sent the results by fax to the home care agency, who in turn faxed it to the primary care physician. On arrival at the specialist, they did not have the lab results. A few phone calls determined that the home nursing care agency had faxed the lab results to a wrong number, and so they re-faxed the results. It was also found out that the primary care physician and the specialist look for lab results in their electronic medical record from their in-house lab, and do not routinely look for lab results in faxed documents. Another similar communication and information technology problem involving a physician, a pharmacy and a pharmacy benefit manager caused a medication to not be refilled promptly, nearly causing a hospital readmission. We have islands of electronic medical records in a sea of paper, faxes and phone calls.

  7. @Brad This isn't a problem with the home care agency, it is a problem with the fragmented nature of healthcare in the United States. Other countries and even the VA here have a centralized patient database. All tests done on patients in those situations are uploaded to the database so there is no need for faxing, printing or phone calls, it immediately gets attached to the patients electronic health record. As it stands as of this date, there is no shared electronic database in the private sector in the US, each office has their own system and they rarely communicate with other offices, nor with pharmacies or diagnostic facilities. It will take patient awareness and outrage to direct change here, not physicians or politicians since each is protecting their own turf. If you are the patients healthcare surrogate, you have direct access to the patients test results and should make a point to gather all tests yourself and bring them with you to the patients doctors' visits. That way, failure of the system will not affect your loved ones health.

  8. A comprehensive plan like Kaiser has basically everything in house. It’s not totally perf3 t and foolproof, bu5 way better than the shattered mosaic most Americans must suffer with.

  9. @Brad : This was another Pres. Obama's program that was to save billions but turned out like the statement "if you like your doctor you can keep him/her". And to date there no good EMR, billions have spent on nonfunctional programs.

  10. Medical care like anything other industry or item in America involves the good, the bad and the ugly. What I mean by this is that anything can helpful but it also can be abused including motherhood, apple pie and health care. Not going to doctors can result in big bills when the patient finally gets deathly sick due to neglect and runs up astronomical bills. The other end is true ie where healthy people go to the doctor every week and take useless, unproven tests, procedures etc. to make big pharmacy/HMOs execs billionaires and/or satisfy the patients' hypo neurosis.

  11. Changing healthcare finance and delivery is REALLY hard. PLEASE don't give up. It is worth doing - We have too many people who will be living with chronic conditions and too many families who will be unable to support them. Hospitals, MDs, need to "share" the improvements that will be realized with their post-acute colleagues and community-based organizations.

  12. all of these programs are good attempts to try to keep healthcare costs down. I believe that the biggest problem with America's healthcare costs are that there are too many hands sharing in the pot. For instance, imagine if all the billing people from hospitals drs offices and insurers were made obsolete. imagine those savings. Imagine a system where patients were shown the risks of treatments vs always being offered the latest and greatest new med/technology. Imagine those cost savings. That would be extra base hits, and we won't really ever get that until we have more centralized health care ( public or private) that eliminates these unnecessary costs.

  13. A subject that’s very difficult for a layman to get a handle on: one one side, doctors, hospitals, and labs scream MediCare payments are way too low, sometimes lower than their costs, and you hear of doctors turning away MediCare patients because they’re basically not worth treating, fee wise. On the other hand, we read of doctors in places like Florida and Texas bilking MediCare of $20... 40... 60 million in fraudulent Billings. And a patient who must go in for essential treatment? She doesn’t have any idea of what the cost will be until it’s all over.

  14. @Pottree Doc here. We can make a little on Medicare. We lose on Medicaid. I have begged my group many times to stop taking new Medicaid players.

  15. Time to focus on social services and public health for a fraction of the cost of health care. You can change health care financing incentives all you want but health care providers’ hands are tied when they take care of patients who are overwhelmed with housing instability, cost of child care, crushing debt.

  16. Medicare population is the richest cohort, has no kids, and many have paid off their homes. Poverty rates are lowest in elderly population, by design (social security provides a floor and many have retirement savings). Yes, there are some poor folks eligible for Medicare, but if you can’t see results in this population where do you expect to see results?

  17. @James The children who are taking care of the Medicare population are Sandwiched between kids, their problems, and their Medicare parents. Why is this difficult to understand?

  18. To paraphrase an infamous pundit who happens to occupy the Oval Office: "Who knew that health care could be so complicated." Not mentioned here is that enormous pressure is put on physicians to meet "productivity" goals which means that they spend less time with patients and more of that precious time is spent typing into EHR computer systems than actually listening to, looking at and talking to the patient.

  19. Family doc here. The idea that a few percentage points or even 20 will change our behavior is absurd. There is a shortage. I'm doing what I can do. It's more important to most of us to get enough sleep than it is to meet whatever BS metrics the feds spew out. Push us too far and we'll just stop taking Medicare. Got enough insured patients. I have already recommended this to my group. Same with work-related injuries. Too much paperwork.

  20. The value reforms put forth in the policy refer to one area of care: persistent disease, as if this is the only type of care required. There are 3 more areas: preventative, emergency/urgent and palliative, all with massively different requirements and evaluations of value. Worldwide, countries have struggled to address persistent disease. Those that universalize care fail the worst. Quality in care cannot be achieved until the market is broken up. With more experience and better analysis, you will find that preventive care is best handled with free markets, emergency/urgent care with insurance, persistent disease with profit centered competitive membership models, and palliative with a stipend model. The nanny state in healthcare is a scam.

  21. The structural problem with American healthcare is that in general there is no single entity responsible and accountable for the care of a person. An entity that is rewarded for quality and better outcomes, and conversely penalized for poor ones. Medicare and Medicaid fractionalize the human being into arbitrary parts, and neither integrate timely data from the home, where patients spend (and want to spend) their lives. And most people in healthcare get pretty well paid to do what they're doing, so only big carrots or heavy sticks have impact. The attempts to institute value-based programs so far has just led to a scramble to see who ends up standing when the musical chairs of accountability music ends. For a dissection of achieving Better Care for All, see https://medium.com/@robertmherzog/bettercare-for-all-c679eca11043

  22. Researchers and health professionals adhere to bioethical constructs to protect human subjects – but not health policy designers. They harm tens of millions. HITECH to ACA to MACRA to Readmissions to Primary Care Medical Home to Value Based has shifted hundreds of billions away from counties in most need of dollars, health workforce, access, jobs, and economics. These dollars are now even more concentrated in the hands of CEOs, corporations, and consultants that do not deliver care. The health insurance expansion plans are meaningless for care where most needed. The dollars go away from these counties and few return to support local health care. The metrics, measurements, and micromanagements have extracted billions more each year from practices and hospitals where they are most needed. For example there were about 60,000 primary care physicians in 2621 counties lowest in health care workforce with 40% of the population in 2010. This is about half enough to go with half enough general specialists as well. These primary care practices had 38 billion to invest in primary care delivery, but HITECH to MACRA to Primary Care Medical Home has stolen 8 billion, leaving only 30 billion by 2018. These practices often could not pay for certified EHR because CMS and payers pay too little already.

  23. But wait, there is more than just health care discrimination. Consider that schools, teachers, and districts have also had billions extracted to pay for metrics, measurements, and micromanagements. These have not improved outcomes as outcomes are about the population, and not the practice or school or teacher or provider. This has been meaningless, abusive, and discriminatory against local health care and local education where most needed. The performance based designs cannot address the major determinants of outcomes (personal, situational, environmental, relational, social, genetics) – but they hold practices and hospitals responsible. So those caring for populations with inherently worse outcomes are penalized. Readmissions penalties year 2 resulted in the top 1 – 2% penalty for 3% of urban hospitals, 5% overall, 9% of rural hospitals, and 14% of the hospitals in these 2621 counties. Who would think that places with inherently lesser health outcomes and lowest health literacy and least local workforce and fewest local support resources would have a chance under such abusive performance based designs? And if you want to map out these 2621 counties lowest in health care workforce that are most abused by health and education designs at the federal and state and corporation levels - they map out as the Red Counties. And they are growing fastest in population numbers, demand, and complexity while their health care workforce is declining by design.

  24. We have a broken system, if it can even be considered a "system". At best, we have a low value healthcare system that pales in comparison to virtually all of our peers. Our outcomes for most key measures of overall system effectiveness are at the bottom of the list (access to appropriate care, cost per person, life expectancy, infant mortality, use of evidence-based practices, percentage of care with no meaningful benefit, etc). Our costs are exponentially higher. An honest assessment of improvements in the effectiveness of our system over the past 10, 20 or 30 years would show paltry gains in only a handful of key metrics. Building around the edges of the present system will get us exactly where we are now. The Affordable Care Act payment innovation system did exactly that - build around the edges with such minimal impact that there would not be major resistance. The results were predictable. Many of the comments in here are a microcosm of what we face - we all agree that our system has issues, but "my sector of healthcare is not one of them". It's always bad data or the wrong measure. Everyone has a chip on their shoulder. More importantly, too many profit handsomely from the present inefficiencies and will "circle the wagons" at any sign of threat. Until we are willing to accept that there will be, and must be, losers....we will only scratch around the edges of the lowest value health system the developed world has ever seen.

  25. Most of these systems have been very poorly designed. As mentioned, the incentives are very weak. The quality measures are suspect. In my experience, with physician run ACOs the group will simply fire the high cost physicians. This leaves them with the cost effective physicians who were providing cost effective care all along. Medicare counts this as a win. In reality there has been no change in overall cost.

  26. The healthcare industrial complex is much more powerful than the government or military. While Medicare's show of gains through incentive programs created modest traction, similar programs initiated by large commercial payers has caused massive market consolidation on the provider side. This consolidation has shifted economic power away from physicians and their patients to hospital systems. Now, using non-profit income tax shelters, these systems are building new hospitals that typically run low census rates while adding fixed costs for those who pay premiums. Individuals are left with higher premiums, copays and deductibles as a result of decreased provider competition. There can be little doubt that only a major shift in the financing of US healthcare will keep most people covered.

  27. The author and his editors should have mentioned the ultimate value and cost cure for Medicare -- HMOs, most recently called "Advantage" plans. Prior to that they were called "Choice" in spite of narrow networks. Numerous independent reports, plus GAO reports, show these fixed payment systems have not saved money and in fact cost more than FFS Medicare. And they don't publicly report actual patient outcomes unless they find a metric they want to report for political or PR purposes. Wouldn't everyone agree that walking out of the hospital after an acute heart attack is good value? Ditto for being alive one year later. And so is having excellent functional status free of heart failure, chest pain and stroke? Yet Medicare HMOs don't report these metrics. Most value metrics used by the various "value" schemes aren't actual outcomes. They are process measures that can be gamed -- like blood pressure. The value game is rigged by the promoters and grifters who have made $billions off managed care. Meanwhile over 50% of doctors are burned out. You don't have to feel sorry for them. Feel sorry for their patients, like breast cancer patients pleading for guideline indicated standard drugs denied by insurance companies. It's not surprising that a recent social media poll about the most important pre-med course for doctors indicated it was "typing."

  28. Alas--the single best way to reduce error & burn out, maximize patient satisfaction and reduce needless costly defensive tests is to incentivize long term primary care relationships. When a patient is known, care is better. When physicians can focus carefully, not rushed or juggling fragmented inputs (like a nurse practitioner doing the history, an aide taking vital signs, a PA performing the physical and an electronic health record jammed with questionnaires and data)- slow medicine prevails. Clinical care is not like any manufacturing model, not a slick hi tech assembly line, and surely beyond the quality control strategies of MBAs. Good care is relational & thoughtful- with sufficient continuity of attention to be efficacious. Otherwise, algorithms generalize care without individual specificity, digital menus measure 'quality' and risk managers determine standards.

  29. More proof that health should not be a for-profit industry.

  30. @AZYankee : The VA is not for profit and look at it's record.Go think about your statement.

  31. What about patient behavior? Health-related lifestyle factors such as inactivity and smoking, that can lead to obesity, diabetes, heart disease, kidney disease? Patients can be non-compliant, not take their medications as prescribed, if at all...skip appointments, ignore recommended lifestyle modifications, remain sedentary, consume too much sodium and alcohol, eat junk food, etc. The United States' high healthcare costs and poor outcomes are attributable, in part, to patients. (Yes, I know, that sounds harsh, but it's true.) Every other high-income nation in the world spends less than the U.S. does as a share of GDP, but surpasses us in most key health outcomes. Do you think if we exported Americans to one of these high-performing countries, the American patient would fare well? Maybe. But, they'd need to make some personal changes -- otherwise we'd run up that country's healthcare costs and reduce their better outcomes. "Value" depends as much on what patients do as what providers do.

  32. Very true. And patient engagement, encouraging patients to adopt healthier habits, is a central element of many value-based strategies.

  33. @Micki: Everybody dies , it is just how much does it cost you to die?