Prescriptions for What Ails Value-Based Care

Everyone seems to be gearing up for value-based care, 2.0. It is hard to argue against the goal of moving from “volume to value.” The jabbing and the jostling are about the best way to get there.

Many value-based programs have been launched. The results have been on the “meh” side: mixed and underwhelming. But a new administration in Washington and the appointment of Liz Fowler as director of CMS’ Center for Medicare and Medicaid Innovation (CMMI) are widely seen as an opening to winnow out what hasn’t worked and keep what has.

In February, the University of Pennsylvania’s Leonard Davis Institute of Health Economics took a crack at it in a white paper at sizing up what should happen next with value-based care. Among the suggestions: Simplify the program offerings, accelerate efforts that include downside risk and put an emphasis on health equity.

In June, it was the turn of the experts at the Duke-Margolis Center for Health Policy at Duke University. In a two-part Health Affairs blog post, Mark B. McClellan, M.D., Ph.D., founding director of the center and FDA commissioner and CMS administrator during the George W. Bush administration, and his colleagues outlined “lessons learned” from valued-based payment models over the past decade and what they mean for CMS and CMMI. Among their observations was a shortage of specialists in payment reform efforts (see our story on page 50). So far, much of the attention in value-based care models has been on primary care, but the Duke-Margolis team points out that primary care accounts for only 6% to 8% of U.S. healthcare spending.

McClellan and his colleagues also noted that for all its problems, fee-for-service payment has the virtue of being based on a standardized, Medicare-based coding system. The proliferation of value-based care models has led to many different ways of measuring cost, outcomes and quality. “This can be particularly challenging for smaller providers when there are multiple related,” McClellan and his colleagues noted. For similar reasons, they see advantages to multipayer reforms, such as Washington State’s Multipayer Primary Care Transformation Model, a value-based care initiative targeting primary care, and Maryland’s all-payer model, which sets global budgets for hospitals.