Opportunities, Tensions, and Growing Pains on the Road to Value-Based Care

The number of Americans covered by accountable care organizations (ACOs) is increasing steadily, but according to a new JAMA commentary, the movement—and that towards value-based care overall—is experiencing some growing pains.

The Viewpoint piece, authored by Harvard Medical School’s Ishani Ganguli, MD, MPH and Timothy Ferris, MD, MPH, points to 2 key issues: fragmentation of value efforts and the lingering incentives of fee-for-service. While there is plenty of aspiration, policy goals remain abstract and meaningful quality measures are hard to define and implement.

Clinicians in system-based ACOs “face a complicated calculus” while navigating the shift, the pair write. Because so much of the healthcare system was built on fee-for-service, the savings gleaned from population health management initiatives don’t always cover other revenue losses, which can sometimes discourage innovative programs.

Quality measurement is difficult for a number of reasons. There isn’t necessarily a consensus around what “quality” actually means, and choosing which measurements are relevant can be a challenge.

“There’s always going to be a tension between standardization or picking measures that can be applied across institutions, and picking measures that have local or clinical significance, meaningful implications to better care,” Ganguli told Healthcare Analytics News in an interview. In addition to being a health services researcher and instructor at Harvard Medical School, she’s also a primary care physician at Brigham and Women’s Hospital. She said quality measures often take the form of checkboxes, which don’t naturally integrate into point-of-care patient interactions.

“The technology really plays a big role,” she said, adding that the data-gathering aspect can be disruptive. “I think a lot about this in my own interactions with patients. If there were reliable technological approaches to capture some of these data in real time in ways that didn’t require me to be cognizant, ‘I’m getting this blood pressure for this purpose…’ that would go a long way.”

Value-based care can also create tensions for many leaders in top healthcare institutions, Ferris and Ganguli write. On one hand, there’s pressure to promote value-based care, while on another there’s competitive pressure to, “build larger and more prestigious institutions, increase market share, buy expensive technology, and evaluate physicians based on the financial bottom line.”

Leaders must demonstrate a commitment to increasing value, the pair argue, through both words and actions.

The new ACO model does provide an opportunity to innovate. As an example, Ganguli pointed to a program she worked on recently to replace or supplement some in-person interactions with patient education videos created by physicians. In the resulting report, 86% of responding patients expressed that the videos helped them better understand their conditions. Although such programs can help reduce readmissions long-term, they cost money to launch and can take time to show their financial benefit.

The JAMA commentary notes that those factors can keep organizations away. Still, the authors write that the difficulties will be worth the trouble if the result is better patient care down the road.

“Some of these things were expected consequences of the transition itself,” Ganguli said. “As larger shares of health systems’ patients fall under value-based payments, they will have an easier time aligning incentives all the way down to clinicians and patients.”