The Evidence Supporting VBP in Health Reform

Although very supportive of the idea of value-based purchasing (VBP), Ateev Mehrotra, MD, MPH, associate professor of healthcare policy and medicine at Harvard Medical School and a hospitalist at Beth Israel Deaconess Medical Center, points out that we do not have much evidence, at least in the classic sense, that VBP works. He is surprised that so much time and energy is being devoted, even on the federal level, to moving forward with VBP as an integral part of the healthcare system.

The evidence is out there, but for various reasons it may not be published, counters Francois de Brantes, MS, MBA, executive director of the Healthcare Incentives Improvement Institute. He has been working with health plans that have deployed value-based payment programs, monitoring quality and cost-of-care improvements over time. The reason more VBP results have not been published in case study form or other forms, says Mr de Brantes, is that they are considered proprietary and perceived to provide a competitive advantage in the field. Plans want to leverage this advantage, ultimately by publishing lower premium rates than their competitors on the state health insurance exchanges.

Another problem with publishing VBP results, according to Mr. de Brantes, is the difficulty of meeting the demand for perfect study designs. He points out that case studies are the more expedient form of publishing best practices and disseminating these results. He emphasizes also that in other sectors, CEOs and policy makers make their decisions on how to set their strategies or allocate their resources “without waiting for published studies to do it.”

Dennis Patrick Scanlon, PhD, professor of health policy and administration and director of the Center for Healthcare Policy Research in the College of Health and Human Development at the Pennsylvania State, asks whether the effort to link payment to a VBP measure that may be controversial is a valid excuse for not moving the field forward.

This is true to some extent, Mr de Brantes replies. “In trying to pair quality measures with [service] bundles in a report for the state of Tennessee, we could find quality measures for about two-thirds of the bundles.” Of these, only about one-half had very distinct measures, he reports. He laid this problem on the provider’s doorstep, claiming that medical specialty societies have “have co-opted the measurement system to make sure that the only measures that see the light of day are measures that cannot distinguish your performance.”

It is not always easy to measure quality, stresses Arthur Vercillo, MD, FACS, regional president of Excellus Blue Cross Blue Shield. Numbers are important in medicine, whether they’re cholesterol counts, blood pressure readings, or glycated hemoglobin levels, but there is much in medicine and healthcare delivery that can’t be measured. He is not convinced that getting exact number on everything is possible, but does believe that the way care is being delivered will improve as forward progression in VBP continues.