Some things in medicine come and go.

Many trends — demands on our time or our practice — start off as the trend du jour but eventually get abandoned for new trends on the horizon.

But there is one trend in medicine that appears to be here to stay— and it’s coming to your state and town, whether you are ready or not.

That trend that’s here to stay?  Value-based payment in medicine.

As Fierce Healthcare summarizes, in just 5 years, 700% more states have adopted value-based payment (VBP) systems. Currently, only 4 states have yet to launch a value-based model.

What does that mean for most healthcare providers?  It means that it's not enough to simply put our heads down and provide good care for the patient in front of us. In a value-based model, it becomes very much "our problem" whether care coordination happens, whether we need to do medical collaboration, and what "non-medical" things are affecting our patients.

For instance, in a value-based model, there are concrete consequences to referring a patient to a doctor 3 hours away and hoping the patient gets an appointment and that they actually go. The patient may not make it to the appointment, end up with a bad outcome, and ultimately — in addition to the subpar care — it becomes a financial hit for the doctor and her organization.  Far better?  Use a system like iClickCare to get a 2-minute consult from that provider, while the patient is in front of you. 

For a long time, healthcare providers felt that medical collaboration and care coordination were altruistic things they would do "when they had time."  In a VBP world, collaboration and coordination are the most practical, incentivized activities in healthcare. Coordinating a medical team means that followup care happens and readmissions drop. Medical collaboration means that you can efficiently pull in providers across the continuum of care to determine the best possible course of treatment — decreasing length of stay.

It's not always the case that the right thing to do and the selfish thing to do are the same. But in a VBP world, the right thing and the selfish thing are the same — use medical collaboration, telemedicine, and care coordination to care for our patients. 

You can try iClickCare for free. Get started in 5 minutes or less here: 

The New England Journal of Medicine's Catalyst blog has been doing a really strong job recently -- and their post on value-based care captures the challenging, difficult, and opportunity-filled place we're at in medicine, right now. 

If, as a healthcare provider, you've ever felt like the definition of "value," and how your organization pursues it, is a moving target... or if you've wondered what direction the whole reimbursement system is moving in... then this piece may have some fascinating insights for you, especially as we start 2019.

There has been a remarkable change in how reimbursement happens, even in the last couple of years. Now, a full 25% of healthcare is based on value-based reimbursement, as reported in JAMA (with the other 75% remaining fee-for-service.)

As you're likely aware, this value-based reimbursement is done in two ways: 

• 1. Capitated Payments. Accountable Care Organizations ACOs use capitated payments (“subscription” per covered life per month)
• 2.  Bundled payments. One payment, based on the patient's condition, which is split up among whatever services or providers treated that condition.

The mechanics of value-based payment models aren't complicated. But the perceptions of these models, the differing levels of support, and our diverse abilities to meet the models' challenges, all vary dramatically. So JAMA's New Marketplaces Insight Report, exploring the understanding and thoughts of different players in the healthcare system around these shifts, is fascinating.

First and foremost, the report suggests deep ambivalence: "Nearly half (46%) of respondents — who are clinical leaders, clinicians, and executives at U.S.-based organizations that deliver health care — say value-based contracts significantly improve the quality of care, and another 42% say value-based contracts significantly lower the cost of care."  In other words, half of us believe value-based contracts are great for quality and half of us believe that they're very bad for quality. Perhaps not surprisingly, healthcare providers tend to be more skeptical about the model than executives and administrators.

Also, many, across organizations and despite their roles, don't know their organization's stance on value-based care. The authors indicate that respondent answers may show a lack of consensus on what value-based care really means. "While there is broad agreement that value in health care is represented by the balance between the patient-centered outcomes of care achieved with the costs to reach those outcomes, many individuals do not completely understand that concept." For instance, one clinician asserts that "value" isn't really a term that is useful or has a broadly understood meaning: "Right now, [value is] a convenient term that means whatever the speaker wants it to mean.”

Payers and providers are not aligned. And the high rate of salaried employment by healthcare systems adds to the confusion. Many clinicians tend to have the starting point that, "I am morally obligated to my patient, but there is no real contract between the patient and myself." 

Regardless of current perceptions, there also remain practical barriers to full adoption of value-based care models. The primary barriers to the proliferation of value-based models are primarily related to infrastructure, including Information Technology. But regulatory issues, data integration, patient engagement, and others all play a role.

Of course, many of these barriers can be addressed by new tools, like iClickCare. But adoption is an interesting challenge when so many providers are ambivalent about whether value-based care is the right direction... or even how their organization is currently reimbursed.

To me, these shifts emphasize the crucial importance of healthcare collaboration. Wherever you or your organization falls regarding reimbursement, healthcare collaboration has become increasingly critical for doing the care coordination and achieving the outcomes that reimbursement shifts demand. I thought that an executive at a large nonprofit hospital in the South articulated the challenge -- and the opportunity -- of healthcare collaboration well: 

"Physicians had been taught for decades that they were the final arbiter of everything that happens to their patient. When, and until, we change the culture to one of team-based care where the patient belongs to the team, we will continue to struggle with adopting value-based care. As an example, a physician with a length of stay that is 10 days longer than his peer average once told me that the hospital has a length of stay problem because the hospital gets paid a single fee for the entirety of care.”

Clinicians are decreasingly able to bury their heads in the sand when it comes to the big picture of reimbursement. But rising to the challenge of what's to come in healthcare doesn't have to be complicated. Simply working effectively with your colleagues to provide the best, most coordinated, most efficient care possible will ultimately be the best approach -- now, and in the future. 

To learn more about how telemedicine can support value-based payment models, download our free Quick Guide: 

There has certainly been a trend in medicine towards centralization, silo-ization and consolidation.

I think that you can see it best in the reverence many patients have for major hospital systems. When someone has a challenging diagnosis, the first thought is always to find the biggest, most well-known hospital system, and pursue “the best” care, there.

But a systematic study I read last week upended all of that, showing that mergers and consolidations may actually increase costs and prices.

I believe there is also a somewhat superstitious sense within the medical community that small, community-based approaches may be “nice” but that they are inherently less efficient and more costly than consolidated, centralized approaches. When I was in private practice, there was always an underlying understanding that it may be quaint to practice in a small, community-based medical group but that it would be more efficient -- in cost savings to us and price savings to the patient -- to practice within a hospital system instead. 

This never sat well with me, even though I could hope for the myriad efficiencies that streamlined communication and thoughtful care were creating. So I was curious to read this study that looked at the effect of hospital mergers 2010-2013 in 25 metropolitan areas. 

Overall, the study showed that prices in most areas increased between 11% and 54% for years after the merger, in most areas. And, “prices rise even more steeply when these large hospital systems buy doctors’ groups, according to Richard Scheffler, director of the Petris Center. It's hard to tell from the data whether the price increases come from increased costs or from decreased competition (meaning higher prices due to market distortions.) 

Consolidations don't seem to be slowing. And the biggest of the bunch -- for instance Dignity Health and Catholic Health Initiatives, have 139 hospitals in 28 states and are truly staggering in size. As these consolidations happen, prices rise consistently and often, hospital access goes down as patients are forced to travel farther for care.

Truth be told, I don't know enough about the vagaries of incentives or regulations at the macroeconomic level to suggest a solution. But I do think that the phenomena themselves, as described by the study, suggest the value of diversity in our healthcare system. 

Bigger and more centralized is not always better. The way to achieve efficiency and scale is by more types of providers working more closely together -- across lines of specialty, training, geography, and time -- not by mergers. Yes, a diverse coalition of the small -- rather than a forcing of everyone to become big -- requires more tools and sophistication. But I believe that healthcare collaboration is a better route to efficiency and access than every hospital becoming a mega-hospital. 

To learn more about alternatives to consolidation and mergers, download our Quick Guide to telemedicine: 

Most healthcare providers let “innovations around reimbursement” come and go.

The majority of us — whether we’re aides, nurses, specialists, or generalists — try to provide the best care possible, in as reasonable a way as possible. And we let the reimbursement and payment fall however it does, after the fact.

That said, there are certainly big shifts that affect how we care for patients — and certainly how we’re paid to do so. And “bundled payments” are one of those shifts that are big enough to pay attention to.

A New York Times article did a thoughtful review recently of Medicare’s bundled payments programs. Currently, these programs are effectively pilots, with hospitals able to opt into the program, rather than making them mandatory.

As I’m sure you’re aware, bundled payment programs create a single payment for every health care service associated with an event. (Rather than paying for the healthcare services individually.) The idea, of course, is that this approach would decrease costs: “In theory, if doctors and hospitals get one payment encompassing all this, they will better coordinate their efforts to limit waste and keep costs down.”

Of course, anyone who has ever gotten a “meal deal” because it was a better value — even though they weren’t originally planing on buying chips or a drink — understands why this may not be the best idea.

That said, some data shows that at least for hip and knee replacements, overall costs are slightly lower than with fee-for-service models. But different types of healthcare are different. And data on hip and knee replacements may not relate at all to other areas of healthcare — especially when the data is coming entirely from hospitals who have opted into the program (rather than taking part in it mandatorily.

But we have some broader concerns about programs like bundled payments.

5 Reasons Bundled Payment Programs May Not Be a Silver Bullet:

• Most waste isn’t coming from doctors pursuing profit over smart care.
  One core concept in the formulation of this type of program is that providers are seeking profit first and safe, considerate care second. My honest take? This happens, but not very often. And so it's possible that one of the framing ideas is false.
• Savings from bundled payments necessitate collaboration — and collaboration needs tools.
  Bundled payments benefit greatly from collaboration that can be empowered by healthcare collaboration tools like iClickCare. But simply changing how things are paid for may not provide the tools necessary to make that collaboration -- and thus the savings -- possible.
• Savings from bundled payments necessitate care coordination — and care coordination demands support.
  This type of integrated payment depends on the interdependency of the providers. As with healthcare collaboration, however, providers are often attempting to coordinate care against all odds. And so it may make more sense to make care coordination more effortless than simply to change payment structures.
• The “bundle” might not be the right combination of services.
  The bundling structure assumes that it is known what’s needed for a given healthcare event. The reality?  Healthcare “events” can be unpredictable and complex -- every patient is different.
• Savings are good but rationing usually isn’t.
  The author of the Times article makes a point about steering patient access. While it certainly makes sense to guide patients towards the most appropriate treatments, I worry that this structure can raise the spectre of rationing -- which usually means that people with the least resources end up getting the worst care. Plus, in these programs, quality is generally not taken into account, at least not in very sophisticated ways — especially tracking quality across different groups.

All of the above isn’t to say that an overall shift to value-based care isn’t desirable (plus, it’s likely inevitable.) But we do think that it’s important to advocate for supports for shifts in care and reimbursement — not just change how doctors are paid.

Looking for ways to save costs in your hospital system? Hybrid Store-and-Forward may be the simplest way towards great ROI: 

As a surgeon, I was certainly trained in a culture of respect for high-impact, high-sophistication interventions, like specialized surgeries.

That said, I was also taught that prepping your own patient for surgery, even down to preparing the surgical area with drapes, and checking on your patient frequently in the hours and days after surgery, are equally important. I was taught, too, that every single person on the care team is equally important — and each person on the team may mean the difference between life and death.

I think that the concept of specialized surgery being lauded above all, was winning for a couple of decades. It’s the concept of “only the best for my loved one” and “we took him to the Mayo Clinic” along with respect for research institutions (rather than community hospitals.) The fee-for-service approach certainly played into this swing. If hospitals are paid most for the most sophisticated, high-intervention care, it’s likely that the trend will be toward that approach.

A further consequence of this previous focus is that when specialized interventions are what matters, it’s the specialist who is valued above all. In that context, the team only exists to support the specialist.

Recently, however, the focus on outcomes-based or value-based care has meant that this high-intervention approach is being called into question.

For instance, two new programs spotlight simple, holistic approaches. This program created a teaching kitchen right next door to the pediatrician’s office, showing families how to improve their nutrition through cooking lessons. And this program reduced readmissions by 27%, cut hospital stays by two days, and saved $3800 per patient — all with a simple $36-per-person nutrition program. In a value-based, fee-for-performance, setting, these types of inexpensive, “unsophisticated” programs may have a bigger effect — and certainly a higher ROI — than the dramatic interventions.

In this context, and with programs like this, medical collaboration becomes the lynchpin. When we are looking at slightly “softer” interventions — like nutrition — everyone from the teacher to the aide to the specialist to the pediatrician to the nutritionist are equally important in the care plan. And those individuals must have the tools to collaborate or the interventions won’t be orchestrated among the providers.

iClickCare has always been oriented toward this kind of holistic, value-based approach. In fact, we started in a school-based health center setting, in which what mattered most was getting students healthy and back to class as efficiently as possible. We created the app to facilitate collaboration among specialists, a pediatrician, and the school-based nurses caring for students. It was holistic, it was team-based, and it was focused on outcomes. In other words -- we had the same values that the future of medicine will. 

If medical collaboration is part of your value-based care strategy, download our free medical collaboration quick guide:

Photo by Brooke Lark on Unsplash

In Liberia, the rate of maternal mortality rates is 725 deaths in every 100,000 live births. That's almost 50 times higher than it is in the US and among the highest rates in the world, even when compared to other developing countries. 

So communities, clinics, and medical providers in Liberia are scrambling for the right solution to get those rates down. According to a New York Times article this month, the consensus seems to be that safer births come from delivering in a clinic or hospital -- under the care of a trained midwife -- rather than at home with the support of a traditional birth attendant. 

That would surprise few people -- but the way they're going about it, as well as the results they are seeing -- are surprising indeed, and are very applicable to our conundrums about value based care, how to improve compliance, and whether care coordination and medical collaboration compliance can be of value in this new climate.

In the Liberian village of Zahmboyee, Evelyn Dolo is a birth attendant who traditionally supports women in giving birth at home. Recently, however, her village created a hugely steep punishment for doing just that. If Evelyn supports a village woman in giving birth at home, the fine is 5,000 Liberian dollars (about $50), a gallon of palm oil and a tub of cooked rice.

So Evelyn, like many traditional birth attendants in Liberia, is rushing patients to clinics rather than attending them at home. The fines vary from community to community -- sometimes the fine is in cattle, or dollar amounts, or rice, or food. But they are usually steep enough to be significant or even catastrophic for a birth attendant. 

Clinics say that they do indeed see more women giving birth in a clinic. And in Liberia, it's too soon to tell whether maternal mortality has shifted significantly. But in other countries, where similar programs are in place, the results simply aren't what people expected. For instance, in India, there has been a program in place to give poor women a cash incentive to give birth in a clinic or birthing facility. Like in Liberia, dramatically more births are happening in a facility -- the number went from 20% to 49% in 5 years -- but there has been no meaningful decrease in Indian maternal mortality rate. 

Lynn Freedman, director of Columbia University’s Averting Maternal Death and Disability program says of coercive punishment or incentive programs: “I don’t think it gets countries or their populations where they want to be.” 

I found this result discouraging when it comes to maternal mortality rates, but also interesting when compared to the pattern we have in the US of creating coercive reward and punishment programs for medical providers around things like care coordination and medical collaboration. Whether it is metrics like length of stay, rate of readmission, or specific patient satisfaction scores, providers are often punished or rewarded for particular indicators -- in the hopes that the hospital system will then experience an improved ROI.

When it comes to value based care, what can we learn from programs like these in Liberia and India?  And do rewards and punishments work in supporting better outcomes and better compliance?  Or is it possible that we can see results like India's, where the behavior we're rewarding increases, but value does not?

3 Reasons Rewards and Punishments Can Fail for Value Based Care:

1. Incentives don't always align with resources. 
   In Liberia's experience, hospitals are seeing more expectant mothers as patients but may not have more money or providers to care for them. As the New York Times points out, "If more women are coming into clinics, then those places need to have increased staffing and supplies to care for them." Similarly, providers are often told there is a new incentive for some aspect of care -- but the time to care for the patient and the support resources to make it happen remain scarce. In a value based care setting, extensive attention needs to be given to having incentives and resources align.
   
   
2. The right incentives have to be given for the right thing. 
   Sometimes the thing that's easy to measure isn't truly the thing of most value. For instance, in the case of maternal mortality rate in Liberia, it's easy to observe whether mothers are giving births in a clinic -- so that is what is being rewarded. But in truth, maternal mortality rate may be helped or hindered in either a home or clinic setting -- so ultimately, when it comes to the end "value" to the patient -- what needs to be measured may be something much more subtle. Similarly, here in the US, hospitals are all going to be on value based care payments. But if providers aren't equipped meaningfully to provide true value (rather than sent on a wild goose chase for metrics that don't really matter), then value for the patient won't really be achieved, even if the metric is met.
3. Providers may become disconnected from their deeper motivations and more important practices. 
   When medical providers, whether in Liberia or in the US, are incentivized for particular behaviors, they start to focus on those actions, rather than the natural things they do to care for the patient in the best way they know how. Not every provider is perfect, but almost every provider is deeply motivated by wanting to help and care for the patient in front of them. In many contexts, that means going above and beyond for the patient, collaborating creatively with other providers, and finding new and better ways to do care coordination because it can help the patient get a better result. Just as Liberian birth attendants may start to become disconnected with their own wisdom about what the patient needs, if there are too many restrictions on how they can care for the patient, the same thing is happening with US medical providers. So many of the incredible people who use iClickCare for care coordination and medical collaboration are doing so because they believe it will help their patients -- not because of any immediate reward or incentive. 

Ultimately, the simple act of trying to care for your patient to get the best possible outcome is the most true act of value based care that can exist. Certainly, hospital systems need to find ways to improve on the value dimensions that are dictating hospital funding. But we advocate for finding a way to do so that doesn't risk alienating medical providers from their most powerful outcome based approaches.

Why not incentivize through enrollment in true understanding of what works and what doesn't in the end outcome, rather than through sticks and carrots linked to simplistic actions? We tend to think that the US is different from a country like Liberia or India -- but we can ignore their learnings at our own risk.

You can use telemedicine to improve performance in value based care. Try it for free here:

Photo by 149720488@N03 on Flickr, used under Creative Commons rights.

Sometimes medical providers have a tendency to focus on the seriousness and sophistication of care. 

When we're about to give a shot, we emphasize that it might hurt. When we prescribe a medicine, we don't always explain the pathway simply -- sometimes we use jargon that makes sense to only the other providers in the room. 

We get most excited about care plans that are cutting edge. 

But a recent study caught my eye as evidence that we might be better off focusing on the simplicity, ease, and fun of a care plan, rather than the more rigorous or medically important aspects.

A recent article in JAMA Internal Medicine looked at the trend of emphasizing the health merits of foods. We see things advertised as high protein, high fiber, or farm-fresh -- and we assume that these descriptors are attractive to people.

As the study reports, "Ironically however, health-focused labeling of food may be counter-effective, as people rate foods that they perceive to be healthier as less tasty."

So the researchers created a study to see whether health-focused labeling is better or worse than just a neutral label -- and better or worse than how junk food is described.

Researchers watched 27,933 students (with some staff) in a dining hall over 46 days. Each day, the researchers offered the same vegetables, but named them differently. For instance, the sweet potatoes might be described as "zesty ginger-turmeric sweet potatoes” instead of just “sweet potatoes." That change, in fact, resulted in 25 percent more people choosing the vegetable. And, as the New York Times summarizes, "35 percent more customers chose the zesty label than the health-positive 'wholesome sweet potato superfood,' and 41 percent more chose it than the scolding 'cholesterol-free sweet potatoes.'"

Across all of the vegetables, the study concludes that vegetables were most likely to be chosen when they had "flavorful, exciting, and indulgent descriptors" rather than neutral ones, or (even worse), descriptors touting their health benefits.

It's a simple study, with results that may seem obvious. But the implications for how you talk about care plans could be significant. It's human nature to want to choose fun things over healthy things -- and there's no reason we can't frame care the same way we frame sweet potatoes. Care coordination is more than assuring appointments are kept; it is about ensuring a good attitude and thus good compliance for improving health. If the patient buys into your recommendations, you are making value, and you will get paid (telehealth with value based care and MACRA).

For instance, your heart patient might need to lose weight so he'll add years to his life. But is it possible that losing weight could also make his August vacation more fun and active? That might be the component to focus on. The shift also makes us reflect on the continuum of care, as different people on the team should be collaborating on things as seemingly mundane as the verbal phrasing of a care plan -- and that requires strong medical collaboration and care coordination -- and a medical collaboration tool. 

Care is far more than how we describe it, of course -- but if subtle changes in verbiage can benefit your patient's outcomes, it could be worth experimenting with.

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Image: Carol Mitchell