Contributor: Why Hasn’t Value-Based Care Delivered on Its Promise at Scale?

Value-based care has gotten a lot of attention in the health care industry over the past 10 years, but the truth is, it has not succeeded in what it was intended to do at scale. In fact, research shows that value-based care models have not lowered costs or improved patient outcomes at scale. Individual contributions to health care expenses have continued to rise without signs of slowing.¹ And over the past decade, the gap in mortality between the US and similar nations has widened and disease burden has worsened.²

This all begs the question: Why isn’t value-based care having the intended effect across the industry? The fundamental tenets of value-based care still hold promise. We have seen some areas where it’s working, like in acute or specialty care. For example, in areas where there’s a focused population like in end-stage kidney disease and oncology, organizations are using focused analytics and care coordination tactics to address avoidable spend holistically.

Asher Perzigian | Image Credit: GCI Health

Value-based care models are meant to lower or slow the growth of the total net costs of care, while improving quality of care at the same time. The industry needs to expand the definition of cost beyond savings generated and understand the true cost of developing, operationalizing, and participating in these programs. The cost elements include provider reimbursement, premium expenses paid by individuals and businesses for health insurance, and administrative expenses, which can be inflated by increased complexity or waste. Organizations also can’t overlook financial and nonfinancial hidden costs for patients as they navigate their health benefits and seek quality care. It is not enough for value-based models to reduce medical expense without controlling for or lowering these other cost categories.

GL Zunker | Image Credit: GCI Health

Once the industry starts driving coordinated evidence-based medicine and orchestrating proactive care across the continuum, value-based care will drive greater impact on a larger scale. There are 4 key challenges health care organizations must overcome first:

1. The missing patient: Current value-based care programs do not consider the patient or caregiver as a part of the design process, nor do they align patient incentives to encourage active participation in their health journey.

Understanding which outcomes matter the most to patients and how they differ by individual allows value-based care contracts to incent the most applicable actions and help ensure insurance plan products reflect patient needs. Moreover, having a collaborative and coordinated care team for each patient—and educating patients on seeking the right level of clinical support—drives better care outcomes. For example, including nurse practitioners and physician assistants in patient care improves the experience while also increasing physician capacity. Patients must not only feel enabled to take part in their own health, but they must also feel that they have a stake in related incentives to truly drive successful value-based care.

2. The quality illusion: Quality and outcomes are not synonyms, but when it comes to value-based care, they should be. To truly measure quality, organizations need to look at patients’ clinical outcomes to understand if care has been effective. By realigning quality to clinical outcomes, we can avoid creating an illusion of improved quality when all that really has been measured is adherence to a process (eg, completed screenings, questionnaires administered). Process measures are important and great tools that indicate imperative care activities but should not be the primary indicators of care quality.

What needs to be tracked is clinical outcomes, patient experience, access and availability and health equity. Quality should be thought of as a holistic indicator of a provider’s ability to impact patient outcomes; a suite of reference measures to compare provider performance; and an accessible metric to empower patient decision-making.

3. The capacity shortage: The primary care labor shortage impacts providers’ ability to succeed in value-based care due to the high demand for health care with limited clinician capacity.³ Highly skilled health care workers are overburdened, and organizations cannot hire or train their way out of this situation. To create capacity, the way in which care is delivered will need to be reimagined with a focus on human + machine. This goes beyond just automating specific tasks in a piecemeal approach—instead we need to fundamentally redesign how work is done to allow clinicians to work at the top of their license while other work is given to other colleagues, machines, or even home caregivers.

Technology and value-based care are fundamentally intertwined — after all, the proliferation of electronic health records have enabled a world in which clinical data can be leveraged to evaluate patient risk and manage quality. Organizations that use emerging technologies to increase physician capacity will be best positioned to take on one of value-based care’s “existential threats”: primary care labor supply.

4. The complexity concern: Successful value-based care requires additional capabilities to manage populations through training, technology, and data insights to reduce cost of care through outcome improvement.

Foundational capabilities for value-based care such as performance reporting tools, provider engagement teams, care coordination, population health management tools, and utilization management tools must interact to allow for better patient management and remove unnecessary administrative burden. These capabilities require both financial investment and a commitment to changing how provider resources are allocated. While this can be highly disruptive, it’s the only way to truly move the needle and successfully transition their practices.

Value-based care still holds a lot of potential, but the industry has lost sight of what’s needed to truly scale these models. To deliver on the promise of value-based care, organizations need to return to the fundamental objective: to deliver high-quality, affordable care to our communities.

Accenture’s Matt Groff and Ashlee Sprague Nicola also contributed to this article.

References

1. Current versus constant (or real) dollars. US Census Bureau. September 12, 2024. Accessed April 3, 2024. https://www.census.gov/topics/income-poverty/income/guidance/current-vs-constant-dollars.html

2. Telesford I, Wager E, Amin K, Cox C. How does the quality of the U.S. health system compare to other countries? Peterson-KFF Health System Tracker. October 23, 2023. Accessed April 3, 2024. https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/#:~:text=From%201980%20to%202020%20(the,the%20U.S%20and%20peer%20countries.

3. Shah T, O'Neal M, Grant T. Reinvent care delivery to solve clinical shortage. Accenture. March 2, 2023. Accessed April 3, 2024. https://www.accenture.com/us-en/insights/health/reinvent-care-delivery-solve-clinical-shortage