Patients want safe, affordable, high-quality healthcare and to avoid preventable harms. However, the current system is convoluted, inefficient, and transactional. Payers also seek to limit waste and standardize care, but current business models profit from transactions. Value-based healthcare aims to relate quality and outcomes to affordability via the equation "V=Q/$". However, moving to this model faces barriers around measurement, incentives, and resistance to change from entrenched systems. A new framework is needed that holistically assesses quality using structure, process and outcomes data to inform patients and drive improvements.
2. Value Based Health Care (VBHC):
• Patients want to know where to go to get the care they desire.
• When a condition arises, patients want help managing their condition
and to know where to find Safe, Affordable, Good, Equitable care
for their condition. They hope to trust their care team. (S.A.G.E)
• Patients struggle in a convoluted unpredictable care journey -
disaggregated, transactional, duplicative, inefficient business model.
• Patients would like to avoid preventable harms at all cost (Safety).
What do patients want?
3. Value Based Health Care (VBHC):
•Payers want to optimize care to limit harm and reduce waste.
•Payers want to measure quality for payment incentives with
limited effort.
•Payers seek to standardize care through practice guidelines and
limit customization of care to fit each patient and in each delivery
system.
•Realize payers’ business systems profit greatly from transactional,
disaggregated models – to change would be costly.
What do payers want?
4. Value Based Health Care (VBHC):
•A framework for redesigning healthcare with an emphasis on patient
goals, around the relationships between outcomes (Quality) and
affordability (Price).
•V = Q / $ is an expression of the judgment a patient places on the
relation of the quality of care for the price. (It is not a numeric
expression)
•An episode of care (such as a surgical procedure or an
acute/chronic medical condition) defines a care journey and applies a
business model which sets a price for a bundled set of services.
ACS Mission: dedicated to improving the care of the surgical patient
and to safeguarding standards of care in an optimal and ethical
practice environment.
6. Policy Landscape:
Extremely large federal bureaucracies with hundreds of divisions, not all of which
are aligned.
ACS
Value-base
d Care
Model
Medicare
FDA
CDC
Medicare: Payment
• Quality – MIPS vs MVP
• Innovation Center (CMMI)
• Medicare Advantage (42%), ACOs (20%)
• APM – Episodes of care (Bundles)/Direct Contracting
• FFS/RVUs (38%)
FDA: Safety
• Clinical Decision Support
(Apps) as a medical device
(ACS risk calculator, CoC
Staging App)
CDC: Care Delivery/Pop Health
• Digital Guidelines
• Care Pathway Process Maps/care tracking notation
7. Policy Landscape
ACS Quality
Model ->
Verification
& Quality
Measures
Value-based
Healthcare (VBHC)
Office of Natl
Coordinator (ONC)
Structural
Informatics
Applied Informatics
Knowledge
Management
Value Based Care/Episodes of Care: V=Q/$
• Numerator = Quality (defined by ACS)
• Denominator = Price (defined by payment)
• Production cost (defined by TDABC)
• New payment models (Episodes of Care)
Technology Interoperability
• Platforms/More than EHRs
• Standards & Data definitions
• Exchanges / Translators
• FHIR/CQL/HL7
Specialty Society Role in AI & Digital Healthcare
Specialty as the content/context experts
• Clinical Decision Support (CDS)
• Cohort tracking
• Registries
• Quality reporting
• Research
Risk Calculator
Cancer Staging
9. Most payers take a transactional approach to use quality metrics as a payment incentive
program. CMS applies a large library of measures across 24 different payment programs.
This fails to create alignment in care delivery and focuses efforts on payment. It is costly
and burdensome to administer with little ROI for quality.
11. It is time to rethink the value proposition.
Episodes of Care
1. Numerator – ACS Quality Model
• ACS Verification opportunities/barriers
• PROs – challenges and barriers
• Sandbox for pilot tests: ACOs and CMMI
2. Denominator – Price
• Legislative overview
• Operational possibilities and barriers
Verification Standards
1. Does the care team
have the right
structures & processes
for the type of care?
2. Can the team identify
when it has a problem?
3. Can they fix it?