By Joseph Burns
Mark Twain once said, “The difference between the almost right word and the right word is really a large matter. ’tis the difference between the lightning bug and the lightning.”
Those of us who cover health insurance might apply this advice when we use the term “value-based care.” While health insurance executives and health system administrators prefer to use this term, what they usually mean instead is “value-based payment.” As Twain warned us, the difference is significant.
During an AHCJ webcast in June, professors from the University of Texas Dell Medical School explained the difference in no uncertain terms. The full webcast is available to members on-demand, along with the presenters’ slides and contact information.
The presenters were Dell Medical School professors Elizabeth Teisberg, Ph.D., executive director of the Value Institute for Health and Care at the University of Texas Dell Medical School, and Scott Wallace, J.D., M.B.A., the institute’s managing director.
For their presentation, they defined value in health care, saying, “Value is the improvement in the health outcomes that matter most to patients for the cost of achieving those outcomes.” If care does not improve a patient’s health, then no value is created.
On the other hand, value-based payment is just that: a payment that a health insurer or other payer makes to physicians and hospitals based on factors the insurer determines, such as improvement in containing costs or meeting certain goals related to processes of care. The later could include immunizing patients or following certain guidelines.
When health insurers and or any health care provider organization says it is delivering value-based care, Teisberg and Wallace said, journalists should ask, “Value for whom?”
Despite making the claim about how care is value-based, care often does not improve results for patients. “The biggest problem in health care is that it doesn’t work well enough,” said Teisberg. “Comparative data show relatively poor health results in the United States compared with that of other OECD countries.” (OECD countries are those 36 members of the Organization of Economic Cooperation and Development.)
While much of the national conversation about health care revolves around reducing costs, spending for health services is only part of what’s needed to improve the health system, she said. “What’s lost is attention to what we get for the money we’re spending.”
Ask about patient outcomes
Wallace explained that while a focus on costs is important, patient outcomes often are not measured. “This surprises people,” he said. “They think their doctor measures outcomes and knows the results of care delivered.”
While physicians and hospitals diligently report and bill for how many and what level of services each patient receives, they rarely know if any patient got better as a result of care.
“Every health care conversation should start by asking: ‘What are your results for individuals and families?’” Wallace added. “Usually, there’s a presumption that outcomes are good, and often that presumption is false.”
To demonstrate patient outcomes, Teisberg and Wallace presented a slide showing different patient outcomes based on where men had surgery for prostate cancer.
After such surgery, some men will have erectile dysfunction, and some will be incontinent. (See slide 3, Average Patient Outcomes After Prostate Cancer Surgery (Germany). This slide showed the average results in all German hospitals for the proportion of patients (94%) who survived five years after surgery, those who had severe ED after one year (75.5%) and the percentage (43.3%) who had severe incontinence after one year.
Now compare those results to the patient outcomes reported after prostate cancer surgery from the Martini Klinik, which is considered to be among the best in Germany (slide 4, Patient Outcomes in Prostate Cancer Differ Significantly by Provider Team). While the five-year survival rates are similar when comparing the average hospital to the best hospital, the percentage of patients with severe ED and severe incontinence varied widely. The rate of complications at the Martini Klinik is about one-fifth of the average for all German hospitals.
Clearly, a German man choosing a hospital for prostate surgery would want to know how the best hospital compared with the average facility. Few, if any, health systems in the United States provide outcomes data with such detail. That leaves U.S. men to choose hospitals based on patient satisfaction scores, Yelp reviews, or other data that are much less important than ED and incontinence rates.
“The clinic with dramatically better outcomes has a very intentional process of learning and improving,” Teisberg explained. Its best practices are repeated for each patient.
“Attention to outcomes can and does drive change, and it enables better results for more patients,” she added. This point is important for journalists and consumers because the absence of outcomes measurement means competitors do not seek to improve, Teisberg said.
Therefore, when health system administrators or health plan executives discuss value-based care, journalists should ask whether outcomes are being collected for every patient served.
What is the evidence?
Teisberg and Wallace also recommended that whenever health system administrators, health care providers, or health insurers discuss their efforts to reduce waste or cut costs, journalists should ask for evidence that they also are improving patient outcomes. Many cost-reduction efforts are not linked to producing good patient outcomes, they said. Yet, achieving good outcomes often will be less costly because good patient outcomes can reduce complications and limit disease progression.
Teisberg and Wallace drew an important distinction between improving processes and producing better outcomes. Often health insurers insist that physicians and hospitals improve their processes, such as those outlined in the Healthcare Effectiveness Data and Information Set (HEDIS), a performance improvement tool from the National Committee for Quality Assurance. HEDIS asks health plans to assess, for example, how many children and adults are immunized and how many members have been screened for breast, cervical and colorectal cancer each year. Such data are important and necessary but do not reflect patient outcomes.
Most health care measurement involves collecting data on inputs (process measures in this instance), and not on outcomes (results for patients). Therefore, journalists should ask what outcomes are measured, they said.
Cardiac hospitals, for example, collect data on how long it takes to get a heart attack patient from the door of the facility to the start of the heart-saving procedure of inserting a balloon in an artery. Penn Medicine explains that that door-to-balloon time is an important measure of quality of care for certain patients.
Teisberg and Wallace warned that while a lower door-to-balloon time reflects an improved process, it’s possible to reduce the door-to-balloon time without cutting death rates. “No other business confuses inputs (what the workers do) with outputs (results customers actually experience),” they said. “In any business or service, value is about results: the outcomes achieved for the money spent.”
Too often, health insurers and health care providers describe good quality care or best practices as if such measures were a proxy for patient outcomes when they are not.
When a health plan claims to deliver high-value care, we should ask what outcomes it improves, they suggested. When health care providers discuss a patient’s experiences of care, journalists should ask about outcomes for each patient. While experience is important, experience with health and care needs to include more than experience with the hospitality of the service.
Teisberg and Wallace say the concept of value has been misapplied. Instead of focusing on improving patient outcomes, health systems and health insurers too often put a myopic focus on cost reduction. Cost control alone does not create value for patients. “Value in health care is created by improving each patient’s health outcomes,” they said.
And value-based care involves teams of providers who deliver relationship-centered care that improves health outcomes for each patient.
For more information, see these resources:
- Video: Welcome to the Value Institute for Health and Care
- AHCJ: Finance editor reports on how health systems replace fee-for-service with value-based payment
- AHCJ: When evaluating value-based care, consider whether costs are falling and quality is improving
- AHCJ: Is value-based health care a fad?
- AHCJ: Webcast to focus on the value of ‘value-based’ care
