Why value-based care hasn’t lowered your medical bills [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

Everyone agrees health care should reward better outcomes at lower cost. So why hasn’t it happened? The answer isn’t payment models or policy. It comes down to the everyday choices individual clinicians make, and whether anyone can actually see them. Jeanne Cohen, a health care analytics founder and CEO, argues that the value in value-based care lives in the quality of each clinical decision, not the contract structure around it. This episode is based on her article “The real reason value-based care has not delivered,” published on KevinMD. You will hear why roughly a quarter of U.S. health care spending traces back to unwarranted variation, how ordering an unnecessary scan exposes patients to harm and pushes organizations out of financial alignment, and why the data infrastructure to fix this finally exists. Cohen also explains where AI can help, where it can’t, and why it won’t lower costs on its own. If you want to understand what actually stands between the health care system and the outcomes it keeps promising, this conversation names it directly.

This episode is brought to you by ModMed.

Welcome to your new AI-Powered Practice from ModMed. We’re transforming specialty care by embedding AI Assistants across your entire workflow. Our all-in-one platform of EHR, patient engagement, practice management, and RCM helps reduce repetitive work while keeping you firmly in control.

Trained on de-identified data from nearly a billion patient encounters, this isn’t just smarter software. It’s a new way of working for specialty medicine, more efficient and more connected to the patient experience.

Start building your AI-Powered Practice at modmed.com.

VISIT SPONSOR → https://www.modmed.com/

SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Jeanne Cohen. She’s a health care analytics founder and CEO. Today’s KevinMD article is “The real reason value-based care has not delivered.” Jeanne, welcome to the show.

Jeanne Cohen: Thank you. It’s lovely to be here.

Kevin Pho: All right. Let’s start by briefly sharing your story, and then tell us why you decided to write this article on KevinMD.

Jeanne Cohen: Thank you. Well, Motive Medical Intelligence really began with a mission that we’re still on, which was to identify evidence in health care and to make sure and certain that clinicians had access to it. We started some years ago looking at the increasing volume of evidence, too much for people to stay current with. Yet practitioners, clinicians, want to deliver the best care they can. And so we started looking at this from a decision support perspective, and we’re the first company to make clinical practice guidelines computable, able to be consumed by computers and delivered in the clinical workflow.

As we did more with that, we recognized we really needed better visibility into what clinicians were actually doing. That’s why we started Practicing Wisely, which looks at and evaluates the clinical decisions of individual clinicians. So we are looking at this across all clinical areas. We’re looking at individual decision-making according to the evidence, so we’re doing that comparison. It provides a unique visibility for clinicians into how they’re actually practicing, and this is very valuable from many, many perspectives.

I think none of us as human beings has a 360-degree view of ourselves, not personally or professionally. And really the gathering and presenting of this information is to return to our mission, which is to help people, help clinicians know what they need to know and act on what they need to know and what they do know.

Kevin Pho: All right. So you wrote the article “The real reason value-based care has not delivered.” Tell us why you decided to write this particular article, and then tell us about it for those who didn’t get a chance to read it.

Jeanne Cohen: Great. Well, because there is an absolute connection between individual clinician decisions, the quality of those decisions, and the achievement of the aims of value-based care, which is higher quality care at lower cost. It seemed that it was a good moment to talk about and make explicit this connection.

Value-based care has been something we’ve talked about for quite a while. I would say in the early years it was more of an incantation than a program, but I would say in the last five to seven years there’s been more value-based care, primarily in primary care, not specialists as much as primary care. But value-based care has been focused on payment, on payment mechanisms, and it’s been evaluating care at an organizational level or a process level. So nothing is looking at the key element of success in value-based care, which is the quality of the treatment, the quality of the clinical decisions. And this goes back many years to the seminal Wennberg article, I’m sure you know it, around variation in care as the source of costs and poor outcomes.

And so by looking at individual decisions, we are specifically looking at what we call appropriateness. Was the care necessary? Addressing the unwarranted variation in care. In a fee-for-service system, variation can be buried within volume. In a value-based care system, variation is exposure. It’s structural exposure, it’s care quality exposure, it’s cost exposure. So it seemed, because there is now, I think, another wave of movement toward value-based care for many reasons, like an important moment to start talking about this next level of value-based care, which requires a new way of looking at performance measurement, sort of performance measurement 2.0.

Kevin Pho: And what are some of the reasons why value-based care hasn’t really achieved the aims that you describe?

Jeanne Cohen: Well, there are multiple. It’s like everything in health care. It’s multifactorial. So a lot of the focus initially had to be on the data infrastructure. In order to do value-based care, you had to have data. You had to know what your results were. You had to gather that information. I think health care, when we started talking about value-based care, really underestimated the infrastructure deficiencies, which meant that data was not flowing, the data that was needed, so it took years for that to happen.

You also have the regulatory environment and misaligned incentives. So in the beginning it was carrots, or carrots and sticks, but neither were significant enough to really motivate that change. And I also think organizations struggle with the investment that needs to be made in the change to workflows and the change to operations to bring value-based care in.

I think while we all attached ourselves enthusiastically to the goal of value-based care, which is not only laudable, it’s imperative, I think as an industry we underestimated the steps that needed to be taken to get there. And so we have ended with years of talking about it and working at it, but it has not been as broadly adopted as people would hope. But I think we’re in a place now where that absolutely can happen. I think people want it to happen.

Kevin Pho: So you’re saying that now we do have that technology, we do have that data infrastructure where we can realize some of the goals of value-based care? Do we still have room to move, or do you think that where we are now, we should be able to realize those goals?

Jeanne Cohen: I think we should be able to realize those goals. I think the infrastructure is there, I think the mechanisms are there. And again, so much of the early emphasis was really on the payment structures, on the how of it, not on where the value is in value-based care. We have to get back to the fact that the value is in the quality of care. The value is in the interaction there between the patient and the clinician, and that’s the part that we’re focusing on.

We’re helping to define that value and actually quantify that value, which now makes it possible to go forward in value-based arrangements, because without this visibility into clinician decision-making, you are at risk in a value-based care arrangement. If you do not know the particulars of that, you are at risk on the cost and quality side.

Kevin Pho: So you wrote in your article that the success of value-based care, like you said, hinges on individual clinical decisions rather than policy or payer contracts. So give us an example or scenario of how that individual clinical decision can really impact the goals of value-based care.

Jeanne Cohen: Well, value-based care arrangements are all payments in which there are reimbursement rates tied to how the care is delivered and the volume of care and all of those things, and if you have a clinician who is, for whatever reason, overutilizing, for example, expensive nuclear imaging, you will simply be out of alignment with all of the commitments on the financial side, and you will also be exposing patients unnecessarily, for example, to radiation.

So when we talk about appropriateness of care, we’re sort of looking at three vectors: care that’s high cost, care that has the potential for harm to the patient, and care that’s practiced with unwarranted variation in terms of the evidence. So this is a very fundamental element in value-based care, that you need to be practicing appropriately, not overusing, but also not underusing. We’re also looking at underuse, which is close to preventive care, and we can analyze, in terms of those decisions, the downstream health impact to the patient and the cost to the system of not doing those things. So you really see the clinician decision as the fulcrum of value in this value-based care structure.

Kevin Pho: In your article, you wrote that about 25 percent of U.S. health care spending is wasteful or linked to variation. How much of that is actually recoverable, I guess, under an ideal scenario of how value-based care should be executed?

Jeanne Cohen: Well, we would argue that most of it is recoverable, and it depends on how an organization wants to use it. We can see that this kind of visibility is being used by provider and payer organizations in a number of ways. For example, to put information about clinical decisions in front of primary care physicians so they can refer to specialists who are practicing at a high level, with a high-value, high-appropriateness score. They are also using it, obviously, to steer patients to higher-value providers. They’re using it to form and shape networks, and using it for prior authorization.

So all of these are ways of deploying this, and also using it to educate physicians, to say, “Here’s what we see you’re doing. Here’s how you compare to your peers for this particular intervention, for this kind of patient. Let’s talk about that.” So it’s a way of informing physicians. When we talk to physicians and work with them on the results of their measurement, they’re very open. This is information they haven’t had before.

And you’ll find that this is not related to malfeasance. It’s related to all kinds of much less dramatic and certainly not pernicious things. For example, in one organization there was tremendous overuse of nuclear imaging prior to some kind of therapy, and it turned out that they didn’t have an echocardiogram program in place, which would have enabled them to do that. So many of these things that prevent people from operating on what they know, doing what they know is the best thing, are operational. So this is also valuable to organizations to help them redesign their workflows and make other kinds of modalities available.

Kevin Pho: What’s the current landscape just in general? Because I know that there are some organizations who are doing exactly what we’re discussing today in terms of being transparent and adjusting the workflows and giving that information to clinicians to influence their practices, and of course, some organizations that are not that far down the line. So in general, what’s the current landscape of physician practices when it comes to that transparency of data in order to realize the value of value-based care?

Jeanne Cohen: I think there is much more welcoming of it. I think there’s much more adoption and welcoming. I think physicians, clinicians, now know that measurement can be a positive. This is not about being punitive. This is about informing. So I would say I’m very encouraged. I would say there is near-universal agreement that information like this can be valuable. I think there is a recommitment to making the kinds of changes and investments that need to be made to make this possible, and it’s also become an imperative from a financial and cost perspective. So I think the landscape is good.

Kevin Pho: So do you think that in order to realize the full potential of value-based care, there does need to be more of a policy shift? Because there is still a substantial portion of our health care system that is still fee-for-service, and isn’t that just going to be a permanent impediment to the full realization of value-based care?

Jeanne Cohen: I think possibly. I think there are two things. I think CMS has certainly stated that its objective is to have everyone in Medicare Advantage, which is a form of a value-based care program, obviously a capitated program, by a certain time. I think regulatory policy can help, but the record in health care is not that it always helps. I think some support may be necessary, but it can’t be heavy-handed. I think the government is aware that becoming too involved in the daily operation of medicine in various organizations is probably not a good thing. I think there are things maybe from a reimbursement perspective that could be done that would incentivize people to move more quickly.

Kevin Pho: Now, if you were in charge of our health care system or in charge of Medicare and you were to set policy, tell us what you would like to see in an ideal scenario.

Jeanne Cohen: I think probably it would be much more public discussion about the relationship between the daily activities of health care and the achievement of these goals. Sometimes this is separate. The policy discussion is at another level, as if it has no relationship to what people are doing every single day. I think that would be something that would galvanize the industry to do more, and it would also educate in a way that I think is not clear now. It is surprising when you talk to organizations and to clinicians, the lack of awareness of the connection between the decisions they’re making on a daily basis and performance under value-based care.

Kevin Pho: So are you talking about maybe publicizing some of the quality data? Because I know that we all have quality data. I’m a physician, I get this presented to me. But making those more public, like you said, would galvanize behavior?

Jeanne Cohen: I think so, and you’re seeing some of that already. I think that in terms of the steerage, the various activities around member steerage, those sites and those solutions are showing more and more information to consumers. I think one of the things that’s always been talked about in health care is that consumer power, informed consumers, will help to push change in health care. I do think we’re seeing more of that.

When someone wants to select a physician, they no longer feel as comfortable necessarily just taking what’s offered or what the plan says. They do want more information, and certainly we are supporting solutions, many solutions like that, with information. So I think, again, a much more open sharing of the data and the information, and the reason why that information is important, would galvanize the community beyond what I think is already an increasing and solid set of commitments to try to get there.

Kevin Pho: Now we’re talking, of course, about health care data, so I need to ask about the impact of artificial intelligence. Where do you see the impact of AI affecting the transparency of data, the analysis of data, or even the collection of data going forward?

Jeanne Cohen: Well, of course, it’s huge. I think AI is an analytical tool and can be applied that way. It’s clear to everyone that there are immediate things that can be done to improve productivity that AI can help with. I think in the areas we’re talking about, which is evaluating clinical decisions and so on, I think there you’re going to have a hybrid. Medicine, the practice of medicine, will always need a hybrid approach. AI is a tool that can support, but it can’t replace the human in the loop. And I think while there’s tremendous early enthusiasm for all of this, naturally, we’re going to end at a place where there’s a much more thoughtful and nuanced approach that combines them both.

I think one of the implications of AI, however, is that the skill sets that are going to be valued in health care, as well as everywhere else, are going to shift, and judgment, the ability to discern, discernment and trust, are going to become two very critical parts of what individuals, including clinicians, bring to the world they’re practicing in.

But I think also, and I agree with David Brailer here, I do not think AI is going to impact affordability in health care. I think it will scale and accelerate the pace at which the incentives are deployed, the payment incentives are deployed. I think it’s still the payment system itself that’s going to determine affordability, and that’s something that we all know needs to be looked at, worked on, and changed.

Kevin Pho: We’re talking to Jeanne Cohen. She’s a health care analytics founder and CEO. Today’s KevinMD article is “The real reason value-based care has not delivered.” Jeanne, let’s end with your take-home messages that you want to leave with the KevinMD audience.

Jeanne Cohen: I think the future of health care is bright. I think health care has two things. It has authentic complexity, because it truly is unlike any other industry. It’s existential, it’s human, it’s authentically complex. There also is in health care a great deal of false complication, and so we need always to sort those two things. Where is the authentic complexity, and where can we support and help there and eliminate false complication? So, you know, health care is hard, but the future is bright. It’s hard for the right reasons, and it’s a privilege to be part of health care.

Kevin Pho: Jeanne, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Jeanne Cohen: Thank you so much for inviting me.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes