Getting to better value in US healthcare: Perspectives from high-value providers

All stakeholders in healthcare say they want higher value in healthcare, so on May 7, 2019 AMGA (American Medical Group Association) and the Healthcare Delivery & Policy Program (ASU-HCDPP) at Arizona State University engaged with high value healthcare (HVC) delivery organizations in a series of panel and group discussions to understand what it takes to provide high value care within the constraints of the current regulatory and reimbursement environment; to get their perspective on current public and private initiatives to promote high value care; and to gather their thoughts on barriers to high value care, and what can policy makers and regulators do to encourage high value care nationwide. The meeting consisted of three panel sessions: 

  • Panel 1: Providers delivering high-value care: What does it take and what are the barriers? 
  • Panel 2: Payer-provider strategies that promote high value care 
  • Panel 3: Patients as high-value care partners: Improving engagement within and beyond the clinic 

While the details of each session and specific tactics are provided below (see pdf download), the following set of observations and recommendations may be of particular interest to policy makers and regulators as they try to move the country to high value care: 

1. Payment for healthcare services remains a major barrier. This includes both payment models, as well as the level of reimbursement for healthcare services. Policy makers need to move the system away from fee-for-service (FFS) and toward payment models that give providers flexibility to deliver patient care in the most appropriate fashion and setting (e.g., IP/OP/virtual/in-the-home). In turn, payment levels should be based on real costs of delivering care by high-value organizations; focus on the level of attainment rather than the level of improvement (since the latter tends to penalize high-value providers, while rewarding low-value ones); and better reflect patient populations served through more robust patient attribution and risk adjustment. 

2. Lack of timely and actionable data to design, implement, and evaluate new models of care, was cited as another major barrier to HVC adoption. Policy makers are in a unique position to mandate that all payers (including insurance companies, self-insured employers, government, etc.) provide healthcare delivery organizations with real-time, clinical and financial data, that are structured in ways that help these organizations in their efforts to positively impact patient care. 

3. Lack of standardization and near-exponential growth in the number of quality and “value” measures across payers, has resulted in a heavy reporting burden on providers. Policy makers and regulators should work with providers to establish a limited, yet robust set of value indicators and to mandate the consistent use of these measures across all payers. 

4. Legal and regulatory constructs like scope of practice laws, HIPAA and Stark, tend to limit the hallmarks of high value care, i.e., teamwork and coordination of care around the patient. It may be time to review and revise these constructs in the context of the evolving high value healthcare system. 

5. Finally, policy makers have a key role to play in improving patient health directly. To date, major improvements in health outcomes (e.g., reduction in smoking rates) have come as a result of policy, rather than provider-based patient engagement strategies. Moreover, in many instances, policy makers and government agencies are better positioned than healthcare providers to address the social determinants of health (e.g., education, income, environmental conditions). By better understanding their constituents and leveraging the lessons of behavioral economics, policy makers can influence health outcomes through levers like health benefit design, taxation, educational campaigns, etc. 

In summary, high value care in the US is possible, as many integrated delivery organizations are able to deliver HVC despite the constraints of the current system. Despite the ongoing trend of consolidation, the majority of healthcare in the US is still delivered by independent providers (rather than integrated delivery systems or provider networks). We believe that by addressing the constraints described above, policy makers and regulators can create the necessary conditions to ensure that more providers are successful in their HVC efforts. 

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