High Value Care is health service delivery that maximizes the total benefit to the patient by considering the expenses and potential harms of certain care. It’s a utility-oriented system of healthcare delivery. In all medical care there are typically, at least, four interested parties: the patient, the hospital, the clinician and the insurance company.
High Value Care is the healthcare offspring of economic ‘utility’.
HVC requires the updating of procedural processes as more information becomes available.
Some of the highest-value care is preventative care.
The American College of Physicians defines high-value care as, “health care that balances clinical benefit with costs and harms with the goal of improving patient outcomes.”
The Institute of Medicine defines it as “the best care for the patient, with the optimal result for the circumstances, delivered at the right price.”
In practice this is an effort to reduce wasteful spending; candidate behaviors include avoiding ordering unnecessary tests, reducing lengths of stay when possible and recommending generics whenever possible. Somebody pays for everything that gets done in the hospital so, in a sense, everybody can win.
If High Value Care sounds a bit like “utility” to anybody having taken Econ 101, that’s because HVC is the healthcare offspring of this idea. Utility is derived from usefulness.
Instruments for measuring utility vary and, in general, the optimal outcome for any given patient is a personal determination. Some universal criteria are financial cost and relief of ailment.
Vaccines. Most childhood vaccines are covered by private and public insurances or through childhood vaccine charities. The CDC estimates that vaccines for children born between 1994 and 2018 have prevented approximately 419 million illnesses and generated a net savings of $406 billion in direct costs and nearly $1.9 trillion in social costs. This is the quintessential example of high value care: low upfront costs, reduced disease burden, limited side effects and long-term benefits.
Sometimes high value care isn’t as obvious. Conventional wisdom has been that everybody arriving at a hospital for a heart attack receives a cardiac catheterization – a way to visualize the blood vessels supplying the heart’s muscles to check for blockages or narrowings.
The thinking being that, since heart attacks are caused by reduced coronary artery blood flow, it is essential to visualize the flow through these vessels to the heart’s muscles. Any heart attack is an emergency situation with high mortality; hospitals and physicians have little time to plan for each emergency and often rely on standardized diagnostic and treatment procedures.
Two recent trials have cast doubt on the necessity of angiography for certain types of heart attacks, as determined by EKG. The COACT and TOMAHAWK trials have demonstrated the absence of any survival benefit at 90 days for certain heart-attack patients who had a catheterization performed. At an estimated cost of about $5,000, catheterizations are a substantial financial burden for individuals and systems and it may be entirely unnecessary. So there is no value for patients and significant costs. It is unlikely that any evil intentions led to the standardization of catheterization in heart attack admissions but as new evidence comes to light, it is irresponsible to continue such a practice – both to patients and payers.
Payers are moving toward reimbursement models that incentivize higher-value care by tying payments to health care facilities and clinicians to their performance on selected quality, cost and efficiency measures.
For example, under the CMS Merit-based Incentive Payment System, 5% of clinicians’ revenue in 2020 is tied to their 2018 performance in four categories: Quality, Cost, Improvement Activities and Promoting Interoperability. And the percent of revenue tied to performance in these categories is scheduled to increase in the coming years.
Additionally, bundled payment models are being trialed as a means to move toward value-based care by incentivizing providers to advance coordination and efficiency of care while also improving quality and outcomes at lower costs.
With bundled payments, the total allowable acute and post-acute expenditures (target price) for an episode of care are predetermined. So, providers share in any losses or savings that result from the difference between this target price and actual costs. Providers have ‘skin in the game’ because they assume risk, as they must cover costs that go above the target price for an episode of care including those that arise from complications and hospital readmissions.
On the upside, providers share in the savings if they keep costs below the target price while maintaining quality standards. Bundled payments are showing significant promise in improving care quality while at the same time bringing costs down.
Outside the Huddle
Dartmouth Atlas of Health Care | Dartmouth College
Regional Variations in Back Surgery | NYT – The Upshot
Things We Do For No Reason | Journal of Hospital Medicine