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The Shift to Value-Based Care: Balancing Quality Improvement with Patient Access

November 18, 2015

Over the last few years, there has been a significant shift throughout our health care system to move to a delivery and payment model known as value-based care. And while simple in concept—that is, shifting payment models away from rewarding the volume of care, or number of treatments provided, to instead focus on the value of care, such as quality of care and health outcomes—how to best develop and implement value-based care systems remains highly debated.

Understandably, many stakeholders throughout our health care system are eager to institute policy changes to improve outcomes and, in fact, some have already started to shift toward various value-based models. However, as we make changes, it’s also important to ensure we balance implementing these new value-based payment systems with continuing to eliminate barriers to treatment.

For example, over the last 10 years, employers have increasingly adopted consumer-directed health plans (CDHPs), which—as the National Pharmaceutical Council (NPC) notes, tend to come with lower premiums and higher deductibles. A standard model for CDHPs encourages preventive care and monitoring outcomes—two tenets often included in value-based care models. But there is also huge variability in deductible levels, coverage of prescription drugs, and the amount of wellness support among CDHPs.

In fact, as The American Journal of Managed Care highlights, the variability in plan design and growing number of CDHPs should raise a number of concerns for the health care community.

One issue? Most health insurance plans are formulated to spread the risk across all enrollees so that those who are or become sick are able to receive the critical care they need without significant financial harm. But, in the case of many CDHPs, enrollees who have chronic or serious illness will end up shouldering large deductibles and high out-of-pocket costs. As a result, patients may inappropriately delay or completely decline treatment, skip their medications, and not follow provider guidelines despite their often urgent health needs.

Point for Consideration:

  • Recognize that for employees who are low income or who have high health care needs, consumer-directed health plans can impose a bigger burden of out-of-pocket costs, potentially causing these employees to reduce their compliance with necessary treatments or avoid care altogether. This can contribute to higher health expenditures in the long run.

Instead, other payment models—such as value-based insurance design (V-BID), which links how beneficial a therapy is to the individual patient to how much the patient pays—may offer a better solution for balancing costs with ensuring flexible coverage and protecting patient access to health care services.

Today, flexible plan design has become increasingly important with the advent of new technologies, which more and more allow us to evaluate enormous and complex patient data sets to identify what therapy is likely to best address each condition for the average person.

However, while advancements in treatment comparison have certainly helped numerous patients throughout our health care system, as NPC recently illustrated, it also disregards that no two patients are exactly the same. When a patient enters the health system, the individual brings along his or her own unique set of risk factors, medical history, lifestyle, genetic make-up, and preferences and, as result, may respond differently to what has been determined to be the standard of care.

As such, reforms that are moving toward value-based care, as well as the related quality measures that determine if the changes are successful, should keep in mind that patients respond to treatments differently.

These individual treatment effects, known as heterogeneity, require that those looking to develop and implement new health care payment and delivery models work to balance the value in identifying the most effective treatment solutions for the majority of patients with the reality that not all patients will respond the same way to treatment.

That means that as we continue to think about patient access as a factor in system reform, we need to consider the impact on all patients—including those who may need alternative treatment options—and, as NPC and Auburn University have done, find new ways to help researchers better investigate and understand this issue.

Importantly, as NPC has continued to highlight, restricted access not only affects individual patient health, but could also have significant impact on downstream health care costs as patients’ conditions progress without the use of the most effective treatment and are put at an increased risk for adverse events.

Point for Consideration:

  • Consider flexible health plan designs that take into account individual patient differences. Patients have their own unique set of risk factors, medical history, lifestyle, genetic make-up, and preferences and, as result, may respond differently to what has been determined to be the standard of care. Value-based insurance design or the use of variable copayments are among methods that are currently being tested by payers.

And the best way to ensure patients receive the right care? Many experts believe the answer starts with meaningful quality measures.

As Dr. Cary Sennett, president and CEO of the Asthma and Allergy Foundation of America, noted when he recently spoke with NPC, “Quality measures are a lightning rod that draw our attention to some of the gaps that exist in health care that, without which, there would be no energy for change…there would be no energy for improvement.”

And it’s that focus on filling gaps where they exist and drawing attention to where we can improve that is necessary to take steps toward meaningful changes in how we deliver health care to and ensure access for millions of Americans. However, challenges remain in developing quality measures that respond to individual patient needs and are appropriately designed around patient subgroups.

Still, that doesn’t mean we can’t develop standards of care that can be broadly applied across patient populations. But rather, as Sue Peschin, president and CEO of the Alliance for Aging Research, shared with NPC, quality measures—like many aspects of value-based care—need to balance patient subgroup concerns and access in a real-world, clinical setting with our efforts to develop measures so that, in the end, quality measures truly result in higher quality care for all patients.

Point for Consideration:

  • Understand the gaps in quality measures for high-priority conditions so that we can work to improve measure sets. Measurement in accountable care programs is essential for promoting quality improvement and balancing financial incentives, but gaps in measurement can result in missed opportunities to improve patient care and health systems.

[Note: Previous posts in this series focused on considering all health costs; strengthening an innovative environment; and working together to ensure patient access to treatments and encourage innovation.]

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