Book Review

Best Overview of Value-Based Care So Far

Peter Boland

The authors of Understanding Value-Based Healthcare are respected clinicians and professors. Christopher Moriates, MD, of the University of California–San Francisco; Vineet Arora, MD, of the University of Chicago; and Neel Shah, MD, of Harvard Medical School quoted Donald Berwick, MD, an Obama era CMS administrator and founder of the Institute for Healthcare Improvement, as providing the rationale for this book’s approach to care improvement:

“Government cannot do it. Payers cannot do it. Regulators cannot do it. Only the people who give care can improve it.”

Understanding Value-Based Healthcare

Indeed, individual physicians are the front line and the critical resource for changing how medicine is practiced and, ultimately, it will be up to individual physicians to lead the charge to transform health care. This is a tall order, and Moriates, Arora, and Shah have amassed a comprehensive, three-part compendium on the subject that covers 402 pages and has 1,046 footnotes. The book was published three years ago, but it is the most detailed overview of value-based care and will serve as an essential reference for practitioners as well as industry professionals and policymakers grappling with the complexity of how to reshape the health care system.

Part 1 begins with the recent challenges of producing better care at less cost, how to connect quality to patient safety and costs, and the ethics of cost-conscious care. Part 2 focuses on the myriad causes of waste—including variation in physician practice styles and patient utilization—and barriers to providing high-value care. Part 3 concludes with a discussion of solutions and tools, particularly how to teach cost-conscious awareness to beginning physicians, the role of patients in shared decision making, balancing the benefits and harms of screening and prevention, and detailed suggestions for moving reimbursement from volume to value.

The book is a practical and compelling teaching manual. It cogently introduces the reality that health care costs harm individual patients, a concept that, until recently, had not found its way into medical school curricula. In fact, there is a widespread and deeply held bias that physicians should do everything they can for their patients regardless of costs. The authors persuasively show how this harms patients, many of whom can no longer afford high-priced health (financial harm), and can result in unnecessary services (waste) and even bad care (clinical harm).

The authors cite the widespread use of computed tomography angiography (CTA) to diagnose pulmonary embolism as an example of overuse that can cause harm. As many as a third of the 1.5 million CTAs performed each year in this country are done to rule out pulmonary embolism, according to the authors. Yet diagnosing pulmonary embolisms with CTAs has turned out to have a very small impact on mortality rates. And CTAs expose people to radiation and to intravenous contrast agent, which carries some risk for allergic reactions and kidney failure.

Peter Boland

The authors thoughtfully dissect the multitude of drivers that lead to overuse, medical errors, and preventable complications throughout the medical profession. Equally important, the book explains how clinical practice relates to the price of health care for patients. The difference between what a service costs (and why) and what is charged (and why) is one of the main themes of the book. The lack of pricing transparency and the “sticker shock” of patients experiencing egregiously inflated charges after a hospital stay is told through firsthand patient accounts. These stories ground the abstract issues of pricing data in the reality of people’s lives and, eventually, may help to bring about real reform through consumer-oriented state databases and websites.

Understanding Value-Based Healthcare makes a persuasive case that price and quality transparency are at the heart of value-based care and that it is the responsibility of medical schools to train physicians how to do this. One of the practical ways of teaching value-based care is to model it with everyday examples of cost-conscious behavior. One of the most valuable teaching aids is Cost of Care, a not-for-profit organization directed by Moriates, Arora, and Shah to help patients deal with medical bills by crowdsourcing hundreds of anecdotes pointing out defects in the system, thus illustrating opportunities to improve the value of care. The authors also mention the Choosing Wisely campaign as an ally of value-based care because it discourages overtreatment.

Don’t blame malpractice

Clinician-led efforts to address health care costs and quality are prescribed as the answer to overcoming a long history of failed attempts at cost containment and improving health care value. The authors believe clinician-­led initiatives will work this time around because patients can be rallied around four overriding concepts in relation to value: respect for autonomy (rather than paternalistic clinical practice), beneficence (correcting the lopsided power imbalance between physicians and patients, which requires complete information about the value of care), nonmaleficence (avoiding medical and financial harm), and justice (fair distribution of health care resources at the point of care). The latter brings up notions of “the tragedy of the commons” in so much as doing everything a doctor can do for her patient may result in not enough resources being available to adequately treat another patient.

The authors point out that a fear of rationing is misplaced because rationing—even if it isn’t called that—has been a mainstay of American health care for years. It has occurred through high copayments that limit care options and high premium costs that limit access to needed care. An obvious example is the way United Network for Organ Sharing prioritizes recipients who should receive organ transplants. In contrast, rational decision making stresses how to avoid waste by only providing treatments that match a patient’s needs and circumstances.

Contrary to conventional wisdom, malpractice fears contribute relatively little to overall costs. A much bigger factor is preference-sensitive treatment decisions wherein patents are not adequately informed about possible treatment options and alternatives. Whose job is it to educate patients about choices? It is primarily the physician’s job, and the authors see this as an opportunity to partner with patients in a more meaningful way.

The authors believe that barriers to high-value care can be overcome through a combination of solutions, including improved bedside communication, feedback, and clinical decision-making support. Some of the most common barriers include misaligned financial incentives (seeing the patient in the office because care by phone is not reimbursed), imprecise measurements (claims data do not account for clinical decision making based on individual patient characteristics), health care system fragmentation (a test done at one facility is repeated because the EMRs are not interoperable and the results are not available), and patient expectations (desire to please the patient by ordering advanced imaging for low back pain).

The book acknowledges that the medical profession does not know how quality or value are measured accurately and states that “not everything important can be measured and not everything measured is important.” Too often, quality metrics are composed only of those things that can be easily quantified. As a result, rewarding a narrow set of indicators (“process” measures) may be the medical equivalent of teaching to the test. To counter this tendency, the authors cite Medicare’s Value-Based Purchasing program, bundled payment initiatives, ACOs, and the CMS Innovation Center as contemporary midwives in the transition from fee-for-service to value-based payments.

Doctors, clinicians are key

One of the most useful sections of the book is a step-by-step guide on implementation science to translate clinical-based evidence into everyday practice. High-value interventions are described in great detail in relation to culture, oversight, system change, and training, along with a checklist for each example. Readers are asked to list predisposing factors (barriers and assets) in the clinical setting and to list potential strategies to apply.

Moriates, Arora, and Shah also discuss a number of successful value-based programs around the country. For example: Geisinger Clinic’s ProvenCare, a model bundled payment program where care is guaranteed for elective CABG surgeries, essentially guaranteeing all 40 benchmarks for such things as bypass surgery. Cincinnati Children’s Hospital achieves a 92% adherence rate to best practices in asthma.

The authors conclude with the belief that the future of health care improvement is up to physicians and other clinicians to deliver on the following promise: continuous advancement in care delivery that is safer, more efficient, less costly, and increasingly focused on the needs and experience of patients and families. This book provides an authoritative road map on how to accomplish this goal.

Peter Boland of Boland Healthcare is a health care consultant in Berkeley, Calif., and a member of the Managed Care editorial advisory board.