Studies have found that coordination and management of care for high-risk patients and those with chronic diseases isn’t saving the industry as much money under the value-based care model as expected. But how can the industry expect high-risk patients with complex, chronic conditions to be impacted by simple shifts in care management and coordination when our current healthcare system cannot even ensure or validate that these patients are receiving the right care in the first place? In this article from Accountable Care News, Lonny Reisman, MD, explores whether or not value-based care has left high-risk patients behind.
In a study published in the December 2017 issue of Health Affairs, “Medicare ACO Program Savings Not Tied to Preventable Hospitalizations or Concentrated Among High-Risk Patients,” researchers reached the conclusion that the majority of savings that have been achieved through Accountable Care Organizations have not been tied to preventable hospitalizations or the care management of high-risk patients.
“Better management and coordination of care for costly conditions and high-cost patients have been presumed to be major mechanisms for achieving savings and are widely emphasized in ACOs’ efforts to lower spending,” the article reads. “These strategies are supported by quality measures in ACO contracts that focus predominantly on care coordination, prevention and at-risk populations with specific conditions—particularly cardiovascular disease and diabetes.”
The article continues: “Based on research to date, however, the pattern of savings achieved by ACOs has not clearly suggested that coordination and management of chronic conditions and high-risk patients have been the major drivers [of savings].”1The article then goes on to attribute savings derived from ACOs to other factors, including reduced use of services in skilled nursing facilities, outpatient departments and home health settings.
While the study’s conclusion — that coordination and management of care for high-risk patients and those with chronic diseases isn’t saving the industry as much money under the value-based care model as we had all hoped it would — may seem surprising at first glance, I think the real lesson to be learned here is something else entirely.
Guideline-Directed Medical Therapy
What’s surprising to me is how the industry can expect that high-risk patients — with complex, chronic conditions, medical histories and co-morbidities — can be impacted by simple shifts in care management and coordination when our current healthcare system cannot even ensure or validate that these patients are receiving the right care in the first place. Let me explain what I mean.
“Chronic diseases and conditions — such as heart disease, stroke, cancer, type 2 diabetes, obesity and arthritis — are among the most common, costly and preventable of all health problems,” according to the US Centers for Disease Control and Prevention. In fact, about half of all adults in the US suffer from one or more chronic diseases; and 86% of the nation’s $2.7 trillion annual healthcare expenditures are related to chronic illness and mental health conditions.2Despite the alarming costs, patients afflicted with these acute and chronic conditions are often not receiving optimal care. One study referenced in the New England Journal of Medicinefound that almost half — 46.3% —- of chronically ill participants “did not receive recommended care.”3
‘A Case of Physicians Never Having Prescribed the Medication’
One shocking example of this can be found in a study in the March 2017 issue of the Journal of the American Medical Association. The study found that, of nearly 95,000 patients with a known history of atrial fibrillation who had acute ischemic stroke, an astonishing 83% “were not receiving therapeutic anticoagulation.”4To be clear, this was not a case of patient non-adherence, but rather of physicians never having prescribed the medication in the first place.
And so, going back to the Health Affairsstudy about ACO savings, if care coordinators are ensuring and reinforcing diagnostic and therapeutic strategies that are in line with guideline-directed medical therapy only about half the time in high-risk patients, and physicians are left without access to systems that can challenge and correct these treatment strategies, should we be surprised that the savings we see in value-based care models from care coordination of low-risk patients does not extend to high-risk patients with chronic diseases? In order for care coordination to be successful for high-risk patients, systems that highlight inappropriate care and engage physicians to deliver GDMT need to be embedded in the health IT platforms of ACOs and other value-based care models.
Process v Outcome Measures
Another reason I suspect the ACOs aren’t seeing as much savings from high-risk patients and those with chronic diseases as they had hoped is the industry’s focus on process measures over outcome measures. This lack of clinical nuance only exacerbates the issue of high-risk patients not receiving guideline-directed medical therapy. For example, when measuring whether treatment has been “successful” for a diabetic patient, value-based care models encourage us to look at process measures such as A1c levels or eye exams. But the reality is such process measures are each only a fraction of overall health, and are hardly the basis for assuming overall patient outcomes.
Looking at only process measures as a way to evaluate quality of care is like evaluating a jet plane by checking tire pressure and fuel levels, and assuming that’s enough data to determine whether or not the plane will crash mid-flight; the reality of aviation is that planes must be monitored all the time, throughout flight, and complex, interconnected pieces of information must be considered.
While tire pressure and fuel levels might be up to standards as a process measure, the only outcome that really matters in the long run is whether the plane lands in one piece or crashes. For a diabetic, eye exams and foot exams are important, but we need to be looking at complex, real-time data holistically to predict and preempt adverse events.
Value Metrics May Have Unintended Consequences
The truth is that value-based care models don’t always push us to look at the proxy measures that matter. For example, under the ACA, hospitals with high numbers of heart failure readmissions (if the patients return within 30 days after initial treatment) receive a financial penalty. But a study published in the November 2017 issue of JAMA Cardiologyfound that, while researchers couldn’t prove causation, their research “support the possibility that the [penalty] has had the unintended consequence of increased mortality in patients hospitalized with heart failure.”5
Because value-based care centers on paying physicians and hospitals for the quality—rather than quantity—of care provided, it seems like readmission rates would be a good metric to consider. But when metrics like these are looked at in a vacuum and physicians and hospitals begin making care decisions to avoid penalties rather than to improve lives, overlooking clinical nuance, we as an industry are missing the mark. In the JAMAstudy, heart failure readmissions within 30 days decreased from 20% to 18.4% after the financial penalty was implemented, but mortality rates increased from 7.2% to 8.6% — about 5,400 additional deaths.
While abundantly important at the population level, reliance on process measures at the individual patient level undermines the need for patient-centric delivery of science-based care to reduce health disparities and, yes, reduce costs for the small percentage of patients who drive most medical spending. Value-based care initiatives have done a fine job of lowering costs by reducing the delivery of inefficient care in low-risk populations. What is needed in the high-risk, high-cost realm is a complementary digital solution that addresses the complex clinical needs of this population.
Technology and Collaboration
With the coordination of medical technology and the right (real-time) patient data, there is opportunity to democratize care across the country. We now have technology that offers the ability to deliver insights based on the latest scientific research and approved guidelines. By collecting granular data from a specific patient and interpreting the data against guidelines, we can dramatically lower healthcare costs and improve patient outcomes, saving lives.
We already have at our fingertips everything we need: enough information for Big Data to serve as an analytical bridge between medical guidelines and high-risk patients with chronic conditions. All that’s left is for us to take action. The industry needs to aggregate this critical, life-saving data from historically disparate sources and merge it with evidence-based standards. From there, we can distill the information into easily understood recommendations for physicians, supported by science, to make a difference in the lives of real patients every single day. If payers, providers, manufacturers and IT and analytics experts are willing, we as an industry can work together to preempt avoidable complications associated with chronic disease and realize the promise of value-based care.