The goals of value-based care are well-aligned with the Institute for Healthcare Improvement’s Triple Aim: improved population health, lower health costs, and a better patient experience.
To achieve these goals, doctors must analyze the potential effectiveness and harm of alternate tests and treatments – which is often easier said than done. How can we make it easier for physicians to evaluate available evidence and proactively advise patients of likely outcomes?
With value-based reimbursement programs, physicians need more than just guidelines to shake-up the status quo, markedly improve patient outcomes and reduce the cost of care. Clinicians require solutions that more explicitly identify the value of specific tests and treatments, as well as the potential harm, in order to drive higher utilization of cost-effective interventions and reduce unnecessary or low-value care processes.
Paying for value is a good start, so let’s consider how the current reimbursement programs are impacting the delivery of care.
Money talks
Value-based incentive programs are designed to reward physicians and healthcare organizations for higher-value outcomes and for minimizing unnecessary interventions. Though the transition to value is influencing physician behavior, most providers still largely rely on traditional fee-for-service models for the bulk of their compensation. Even fee-for service models, however, now include quality components that incent clinicians to follow evidence-base care guidelines.
For example, established care guidelines recommend that patients with diabetes, hypertension and other chronic diseases regularly receive preventative care and ongoing treatment from a clinician. Physicians can drive greater patient compliance with these guidelines by establishing proactive outreach programs, such as outbound messaging to patients. By encouraging regular follow-up care, physicians not only drive better outcomes, but also may increase practice revenues from billable office visits and testing.
Many physicians are also subject to Medicare’s Merit-Based Incentive Payment System (MIPS), which incents providers to track quality activities and demonstrate quality performance. Because reimbursements and penalties are both tied to performance, clinicians are motivated to adhere to evidence-based medicine standards.
Accountable care organizations (ACOs) also tie reimbursement to quality activities. By following evidence-based medicine protocols, physicians are more likely to raise their quality scores and qualify for bonuses under track 1 of the Medicare Shared Savings Program (MSSP). Physicians can also earn shared savings if the ACO reduces Medicare costs by more than a minimum amount. Unlike fee-for-service programs, doctors participating in MSSP are financially motivated to be wise stewards of healthcare resources.
Providers are especially motivated to deliver cost-effective care when participating in risk-based payment models, such as an ACO enrolled in track 2 or track 3 of the MSSP, or a Medicare Advantage plan administered by a private insurer. With incomes at risk, physicians are more likely to leverage evidence as a means to maximize care value and encourage patients to seek appropriate preventive care, manage their chronic conditions, and refrain from unnecessary tests and procedures.
Walking the Walk
Financial incentives, even when combined with well-intentioned clinical practice guidelines, sometimes fail to drive the utilization of strong evidence in clinical practice. For example, when new evidence challenges conventional wisdom, inertia may slow changes in practice habits.
Consider the recent and well-publicized study that examined invasive therapy for stable coronary artery disease. In 2007, strong evidence emerged that found a three-drug therapy for chronic stable angina could be as effective as invasive placement of a coronary stent. However, a decade later, cardiologists acknowledge that the (less-expensive) three-drug therapy remains underutilized, while stents were overutilized. Indeed, as recently as 2016 the American College of Cardiology reported that close to 50 percent of stents for non-acute patients were placed without appropriate indications.
Despite strong evidence, physicians often take years to change practice accordingly. Other examples include the use of antibiotics for peptic ulcer disease and upper respiratory infection; knee surgery for meniscal tears; and the use of beta-blockers as the first line of treatment for hypertension
Evidence adoption is further delayed when risk/benefit information for a unique patient is difficult to glean. Recall that most guidelines are generated at a population or policy level and therefore may not align well with the values and preferences of an individual patient. Translating the best and most meaningful evidence into concrete guidance for a specific patient is hardly straightforward, as implied in a recent systematic review of 48 studies and over 13,00 clinicians. According to the authors, clinicians overestimate the benefit of a test or treatment 32 percent of the time and underestimate the risk of harm 34 percent of the time.
Financial Incentive Plus Systematically-Curated Evidence
In order to achieve financial success in value-based payment models, physicians must have access to better tools for evaluating the relative benefits and risks of different interventions.
One such resource is the Choosing Wisely campaign, which the American Board of Internal Medicine launched in 2012. ABIM publishes a list that includes specialty society admonitions about several hundred tests or treatments that should be avoided under specific circumstances. By staying abreast of pertinent details related to their specialty, physicians can improve care and optimize resources.
Other organizations, including the Cochrane Collaboration, specialty society “journal clubs,” and commercial providers of order sets and care plans systematically evaluate new studies to assess their importance for patient outcomes. Furthermore, grassroots coalitions such as Right Care Alliance and TheNNT are also working to identify and reduce overutilized healthcare interventions by clarifying the risks and benefits of various tests and treatments.
To achieve value-based care goals – along with the Triple Aim – we need to leverage technology and equip physicians with tools that facilitate better decision making based on evidence. In order to drive high-quality care and cost-effective outcomes, providers need ready-access to current data so they can assess the effectiveness and overall value of various interventions.
Despite inertia and complexities, with the right tools in place we have the ability to transform the care process and improve population health, lower health costs, and enhance the patient experience.
Ross Ellis, MD is the Medical Director at Zynx Health to help implement evidence-based care guidance across a broad range of health systems in the US, Canada and the Middle East. In his own practice in eastern Pennsylvania he has helped manage clinical decision support for EHR-based workflows. Dr. Ellis completed an MD degree, MPH degree and residency training at Columbia University in New York. He is ABIM-board certified in general internal medicine.