October 19, 2020
Value-Based Healthcare: What it Means for You
PAs Have an Important Role to Play In VBHC
September 20, 2018
By Eileen Denne, CAE, APR
How can you provide the best possible at care at the lowest possible cost for your patients? Consider learning more about value-based healthcare (VBHC).
VBHC is a term many attribute to a 2006 book written by Michael Porter and Elizabeth Teisberg called “Redefining Health Care: Creating Value-Based Competition on Results.” Porter, a Harvard Business School professor, and Teisberg, professor at Dell Medical School at the University of Texas at Austin, define a healthcare system in which all participants are focused on improving value.
AAPA recently spoke to Christopher Moriates, MD, and Richard Bottner, PA-C, at the Dell Medical School, about the significance of VBHC and about Dell Med School’s free interactive learning modules that teach the foundation of VBHC. Moriates is Assistant Dean for Healthcare Value, Associate Chair for Quality, Safety, and Value in the Department of Internal Medicine, and Associate Professor of Internal Medicine. Bottner is a hospitalist, Division of Hospital Medicine, and Clinical Assistant Professor, Department of Internal Medicine.
Q: What is value-based healthcare (VBHC)?
A: In general, VBHC is defined as optimizing outcomes that matter to patients divided by the total cost of care. It’s really important because sometimes when people think of VBHC, since it does incorporate cost, they think of it as advocating for “cheap” healthcare or trying to merely focus on efficiency. In truth, it is really about improving outcomes for patients. And that’s the primary focus: measuring and improving outcomes, but doing that in a way where you are also getting bang for your buck. Essentially when we think about value in any other context in our lives, we think about, ‘What is the quality and how much does it cost’? VBHC is really asking this same question: ‘Is it worth it?’
Q: What are areas of current medical waste and unsustainable costs of care?
A: The National Academy of Medicine estimated that approximately one-third of healthcare costs are considered waste; the money spent on that care doesn’t make people any healthier. Part of that waste are treatments and tests that are well-intentioned but don’t make patients healthier. For example, back surgery in patients who don’t need surgery, or imaging tests and antibiotics in many scenarios. We need to get rid of waste to improve outcomes. Other areas that contribute to healthcare waste are lack of coordination, such as electronic medical records (EMRs), that don’t speak to each other. There are also excessive overhead costs – currently, clinicians have to coordinate with countless insurance companies and plans, which can be quite expensive.
Q: How does VBHC decrease cost?
A: One way that it focuses on decreasing costs is by tackling areas of overuse. We stop doing stuff that doesn’t make people healthier. For example, 40 to 50 percent of people get antibiotics for upper respiratory infections when we know that in the vast majority of these situations, antibiotics are not warranted and do not work. We know that many advanced imaging studies are unnecessary. These interventions are not just wasteful, but they include side-effects that cause harm. For musculoskeletal problems, some patients benefit from surgery, but many don’t. So, if we can provide the care that is truly needed more efficiently, we can simultaneously improve patient outcomes and decrease costs. In addition, the creation of value-based payment models, such as bundled payment and payments that are tied to outcomes, have the potential to disincentivize overuse and thus decrease costs. Lastly, programs that create better health in the community lead to decreased costs for healthcare.
Q: What should PAs understand about healthcare/medical costs and their impact on patients?
A: Healthcare costs affect every level of society, from individual patients to communities to states and to our nation. In 2018, healthcare is more unaffordable than ever before for patients. Warren Buffet calls healthcare costs the “tapeworm eating the economic body of America.” Because we spend so much on healthcare, we’re unable to spend money on education, business, etc. While physicians and PAs did not go to school to treat the Gross Domestic Product (GDP), we need to recognize that costs are critical for the patients sitting in front of us. If we want to improve the care we provide to them, then we must consider their costs and focus on always providing the best possible care at the lowest possible costs. PA program curriculum is jam-packed with clinical information. It is challenging to incorporate systems-based practice of which VBHC may be the most important and timely. PAs should appreciate how incredibly vital their contributions are to improving health economics. As frontline providers, it is often our medical decision-making that could make or break a patient receiving high-quality and high-value care.
Q: Why should/how can PAs be champions for VBHC?
A: PAs are at the forefront of care delivery in collaboration with physicians and other members of the care team. We play vital roles in ordering tests, developing treatment plans, and prescribing medications. As such, PAs can (and should) be champions for value-based healthcare. We must be ever-conscious about opportunities to decrease cost and improve quality. For example, (Rich Bottner, PA-C) I always have a conversation with my patients about insurance and affordability of their healthcare. When we discover that medication cost is leading to non-adherence, I talk to the pharmacist to seek alternatives and the social worker to determine if there are any local, state, or pharmaceutical aid programs. In addition, patients will often request certain diagnostic studies or new medications. While some providers may give in under the guise of patient satisfaction (such as erythromycin for viral upper respiratory infections), this can often be avoided through patient counseling; an art that PAs are well-poised and often looked upon to do.
Our hospital system uses a potassium sliding scale for electrolyte replacement which includes oral and IV medications. IV administration of potassium should only be done for patients with critical potassium levels or patients who have strict NPO orders. In a three-month chart review we found that over 80 percent of IV potassium administrations were inappropriate. This is important because IV potassium is uncomfortable for patients, and more importantly, can lead to thrombophlebitis and adverse events associated with hyperkalemia. Through an ongoing QI effort, we have been able to decrease cost in terms of nursing time to administer complicated IV medications and increased patient satisfaction by avoiding the negative outcomes noted.
Q: What process measures are critical to achieving and monitoring improvement?
A: VBHC is focused on patient-reported outcomes, not just process measures. It’s not about how long patients waited for knee surgery but whether they could walk up the stairs when they got home. That’s the outcome patients care about. We’re also thinking about how we can coordinate with other facilities and provide the highest level of care. Another critical process measure is the Patient-Centered Outcomes Research Institute (PCORI) created by the Affordable Care Act. This entity exists with support from payers including CMS and private insurance companies, and their goal is conducting research using pragmatic methods. Yes, efficacy of a new drug in a randomized control trial is important. But, in our new era of healthcare, that drug’s effectiveness in producing outcomes that patients truly care about is critical.
Q: What is Dell Medical School doing that is unique regarding VBHC?
A: The school is doing a number of things across educational and clinical domains. First, we have focused on integrating VBHC into each layer of how we train healthcare professionals here at Dell Med, including our medical and nursing students, residents, practicing physicians, PAs, and nurses. We’ve created programs to teach the concepts of VBHC. Among the key jewels of that program are the free interactive modules that we created, which are being used by healthcare learners at all levels across the country. The second thing that is unique is the delivery model that UT Health Austin has created, which includes team-based integrated practice units (IPUs) and clinics designed around the needs of patients; for example, women’s health and musculoskeletal. Instead of going to different providers spread all across town – separated by both space and time – the clinics created here co-locate these professionals and focus the clinic around the needs of patients. For example, someone with knee pain could be seen at the knee pain clinic and would receive coordinated care – by a PA or NP, PTs, surgeons (if necessary) – all within the same clinic. The third thing that is unique is the Department of Population Health at Dell Medical School, which works directly with and for the community. In summary, we are teaching about VBHC and creating models and programs that deliver on those ideals.
Dell Medical School VBHC interactive learning modules. PAs can review a maximum of 2.75 AAPA Category 1 CME credit.
Eileen Denne is director of Corporate Communications at AAPA. Contact her at [email protected].