Long-Term Benefits Show the Value of Upfront Investments in Value-Based Care

At an Institute for Value-Based Medicine^® event held in Park City, Utah, in partnership with Intermountain Health, Miriam Godwin, CMMI, National Kidney Foundation, spoke to the role public policy and value-based care play in regard to kidney health. In this interview, she explores more in depth the key issue that comes with balancing immediate cost concerns with long-term health outcomes.

As value-based care models seek to optimize patient care alongside reducing costs, a primary challenge arises as health care systems try to effectively manage the tension between upfront investment and the anticipation of immediate results or benefits. In part 1 of this interview, Godwin speaks to lingering gaps in patients’ kidney care and the value—and need—to think about how long-term outcomes weigh against upfront investments in value-based care.

This transcript has been lightly edited.

Transcript

How do current public policies around kidney health tackle disparities in care access?

I think since the Affordable Care Act [ACA] was signed into law in 2010, the focus has really been on trying to make sure that everybody is insured. And that is obviously one of the biggest disparities that the ACA set out to address, lack of comprehensive health coverage, and that is vital for kidney patients and also kidney patients at risk. They need to have access to health care that is affordable if they are going to have access to high-quality care. So that's the number one thing: assuring that we have as close to comprehensive coverage as possible for kidney patients and kidney patients who at risk.

What are the most significant gaps in care that public policy reformation/value-based care can address?

For the chronic kidney disease population, I would say we are still really struggling with guideline-concordant chronic kidney disease screening, by which I mean people at risk getting an annual EGFR [estimated glomerular filtration rate] and an annual uACR (urine albumin-to-creatine ratio]. These are the 2 lab tests that are performed to monitor kidney function. Most people who are at risk for chronic kidney disease do not know that they are at risk. Most people with chronic kidney disease do not know that they have it, and this is a problem that public policy can help us get at through screening recommendations, through quality measurement, and really even through payment.

But it's going to be really hard to do anything meaningful for the chronic kidney disease population until the health system is doing a better job at detecting chronic kidney disease as early as possible, so that we can use every tool at our disposal to make sure that they're getting high-quality, comprehensive health care in order to either slow the progression of chronic kidney disease, if that's possible, or if it is not possible, to make sure that they're having an optimal start to dialysis, that they're getting a kidney transplant, or if what they want is dialysis at home or palliative care.

What are the biggest challenges in aligning public policy with the clinical needs of kidney patients, particularly when balancing long-term health outcomes with immediate cost concerns?

I think that's the challenge, right? The devil's in the details of value-based care. And I think it sounds like it should be really easy when you say it at a high level and you say, “Oh, well, you know, we're going to do more on the front end. We're going to save money on the back end.” It should be straightforward. It seems like it should be straightforward. And of course, when you actually dive into the weeds of these models, when you see them implemented, it becomes extraordinarily, extraordinarily complicated. And I think one of the biggest challenges that participants in value-based care struggle with is upfront investments, and how can our government do better at providing an upfront incentive to support care transformation?

I think that's probably one of the biggest problems, and it's really hard to solve, because we expect value-based care to save money. And so if you make a big upfront investment at the front end, you've now drastically reduced chances that you're going to save money on the back end. And this is sort of a fundamental tension with these models and with value-based care as a concept.

I think that the other challenge is that there's so much pressure in our system to see really make good impacts in a short timeframe, right? And I see that in my day job; I deal with the administration, I deal with Capitol Hill, and I think everyone is ready to see the transformation happen. They're like, “Nope, we signed up for value-based care, so where's the money we're saving? Where are the better outcomes?” This is a really long game, and it just is not going to happen right away.

I think we need to develop a political tolerance to think longer term about what we need to do in the short term to get the rewards that we all want—which is better health for people, and in the long term, savings on health care. But many, many, many years from now. Unfortunately, that's just not a very palatable argument, because we all want it now. And that's an understandable position.