Defining value-based care
I have no doubt that value-based care (VBC) has the potential to be an improvement, but as the saying goes, “the devil is in the details”. Depending on the resources one refers to, we can find two general definitions or conceptualizations of VBC. Seemingly similar, but practically speaking very different.
Definition 1:
In one definition the focus is exclusively on outcomes and client satisfaction (I am linking a blog on KPIs here to highlight the need to include those in evaluation of one’s services). I totally buy into this. With this in mind, while observable behavior changes measured against objectives are no doubt very important, they are only part of the puzzle. Caregiver, clinician, but distinctly also client/patient experience (i.e. social validity, assent/consent, and personal preferences) should be accounted for. Hanley did a related paper on this a while back. This concept is obviously important across all clients, and no doubt more complex when working with profound individuals with limited and maybe no functional communication repertoires. But, there is no doubt that our science and movement toward compassionate care should position us to take on this challenge.
Definition 2:
In the other iteration of the definition of VBC we see efficiency and some version of relative expense reduction crop up. An equation that represents this conceptualization of VBC is Value = Health outcomes/cost of delivering the outcomes (reference linked below). I do understand why that is relevant and unavoidable in our current economic system. It could be good for our healthcare economy, and can make one or more companies more competitive in the healthcare market. However, it’s not so simple (or at least I don’t think it is).
Under both definitions, and the first to a greater degree, quality is rewarded. In the second, relative cost reduction becomes a focus of prioritization and reward. If the cost reduction targeted is over the care cycle or lifetime of the client, then I can see the potential. If it’s based on short term reduction such as over a limited number of years, then I’m not so sure.
For a VBC model in which there are any contingencies, explicitly or implicitly stated, to reduce cost, a stark reality is that there are a limited number of ways to do that. Some version of either (1) reducing administrative overhead (i.e. the supports that may ultimately help the providers and customers), (2) reducing quantity per client (recommending less services per client for whatever reason), (3) reducing cost of clinical providers (this means paying less). This last point may take various forms. It could mean reduced salaries, it could mean hiring newer and less experienced clinicians, or it could mean larger case loads. Either way, it doesn’t mean paying more. And you know what they say…. You get what you pay for. While the intent may be to reduce redundant costs, that may not be the only outcome.
The takeaway
In evaluating the benefits of VBC, we all need to be informed consumers, and transparency is key. When we have funders, and even providers, pitching a value based care model, we need to know the contract arrangement and specifically the contingencies under which the different “players” are operating to make an informed decision on who those contingencies benefit. They will almost unquestionably benefit funders, and will have some degree of differential benefit to providers, depending on the specific reimbursement model, for example, the absolute vs relative performance models (reference below).
It would seem the ideal solution is evaluating outcomes (performance and satisfaction), while also compensating adequately skilled providers fairly, even for more complex cases with potential for treatment outcomes that may not be so favorable or the treatment effect as proportionally large. A long term savings definitely makes sense to me. If we invest in patients and quality care now, we will want to see a decreased need for services, and an overall reduction of costs, in the long run. Even then, however, we need to be thoughtful not to exclusively be focused on cost savings. Looking at an extreme analogy distinct from autism (so no, I am not saying they are the same), consider folks with end of life complications, or even someone with a terminal illness, where the goal of quality care is to reduce suffering and improve their quality of life in their remaining years. We may not see a financial return on quality care in this case, but, I’d like to think that we can still prioritize quality care over profits in this case.
I support moving toward a model that prioritizes quality and patient satisfaction. I also support a model that yields long term return on invesement. I just think we ought not blindly accept the broad claim that VBC is innately good or the best reimbursement model, which is often implied. When we consider those who are pitching this notion to us, it may be worth evaluating the contingencies under which they operate.
If you have any feedback you think I should consider and perhaps include, please comment below or email me directly at brandon@partnersaba.com.
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