No shortcuts: Value-based care
The promise
Realizing the immense promise of value-based care requires us to reimagine our system. Entirely.
Effective, healing systems are defined by fundamental alignment with the holistic needs of the patient and their preferences. They are driven by qualitative and quantitative data, including outcomes and process measures. They are — by nature — integrated and collaborative.
They are open.
This type of system — one that aligns the needs of the patient, family, providers, and payers in driving improved outcomes, growth, and value for all parties, has only recently become possible.
The absorption of technologies from payers, patients, and providers has finally reached critical mass. Reimbursement is catching up. Patient expectations are driving change. Quality is starting to be measurable, which will lead to consumer visibility into what has to this point been an opaque industry.
Integrated, aligned, unbundled care that eliminates the most-stubborn gaps in healthcare is on the horizon.
And we need a new paradigm if we are going to make this a reality.
Blocks
The prevailing wisdom — especially in the behavioral health startup space — is that a closed system is necessary to own the benefit and capture the entire lifetime value (measured in fee-for-encounter revenue, not necessarily real value) of the patient. This short-sighted approach is a fundamental impediment to success with these efforts. Our collective inability to conceptualize and implement open systems is the single largest impediment to value-based care.
The six basic pillars of VBC, according to Harvard’s Michael Porter:
Organizing care around medical conditions
Measuring outcomes & cost for every patient
Aligning reimbursement with value
Systems integration
Geography of care
Information technology
These are prerequisites to outcomes-driven innovation as much as they are the building blocks. These basic pillars are essential to the long-term success of improved care models, and are all rendered improbable (if not impossible) by our existing, closed systems.
A closed system can be defined by the systematic pressure it exerts on patients and providers to direct care in any manner that deviates from patient needs/desires. These pressures can be explicit or subtle, and range from outright mandates or restrictions to gentle recommendations or referrals. They can be active or passive. There are many kinds of closed systems, but they all systematically and repeatedly operate in ways that are out of alignment with patient needs and preferences.
The types of gaps in closed systems mirror the pillars of VBC:
Lack of organization around conditions
Often in our space this looks like addressing issues consecutively instead of concurrently, or addressing substance use in episodic and siloed care models (primary care vs. specialty treatment).
Lack of outcome measurement
Often as the result (at least in SUD care) due to philosophical misalignment, bandwidth/chaos issues, or paternalistic and/or carceral pressures. Most of the time, marketing and business development is driving this bus, but we are seeing some exciting movement from efforts like the NIDA-funded ASAM/APA AMNet and NAATP’s FoRSE (led by friend of YourPath, Dr. Annie Peters and something we are a part of).
Lack of alignment between reimbursement and value
This systemic issue is especially prevalent in traditional settings, despite some work to create alternative payment models like the Addiction Recovery Home Alternative, the Patient Centered Opioid Addiction Treatment model, and many state-specific payment arrangements developed as part of 1115 Medicaid waivers.
Lack of systems integration
Many of the reasons for lack of integration are specific to the nature of SUD treatment and recovery supports and their historical standing as a service outside of the scope of medical care.
Geography of care
We lack of so much of what would need to be present to even start developing aligned and integrated sub-systems of care in specific geographies, much less nationally-recognized centers of excellence. The existing networks are the result of marketing and half-earned distinctions based on constructed reputations.
Information technology
A lack of adoption of technology solutions is a defining feature of care systems related to SUD. Where technology is used, it is more often used to exert misaligned pressures and prevent integration rather than to support it.
The solutions to these issues are here, now. We have a newfound opportunity to address these blocks from the specific implementation level, and our epistemès and heuristics need to follow suit.
The promise
We don’t need to be all things to all people, but we do need to recognize and behave as if it were the truth. Simple enough in theory. Wickedly difficult in practice.
Part of the reason it is so difficult to implement is that not only does it take competency across a broad spectrum of businesses areas — medical care, behavioral health operations, regulatory and payer navigation, technology implementation, effective marketing etc. — it takes an integrated competency across these pillars united by a intellectually revolutionary way of imagining healthcare. It’s not enough to have individuals who have competency in each function. You can’t smash together a couple providers experienced in traditional clinical operations with an e-commerce tech wizard and expect solid outcomes.
Even if you have all this, the road is uphill. Even with integration across the entirety of the relevant competencies, if we don’t examine our fundamental understanding of systems, we are likely to just recreate the same archaic and broken patterns, and heartbreaking and expensive outcomes. We need to embrace the need for a fundamentally different approach to business and care models developed intentionally to work in open systems.