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Value-Based Healthcare


Tim Casey

Fort Lauderdale—In the United States, approximately 100 million adults have chronic pain, which is associated with $275 billion in healthcare costs and $300 billion in lost worker productivity each year. The combined costs are larger than those for heart disease, cancer, and diabetes, according to Ajay Watson, MD, PhD, a specialist in anesthesia and pain management at Brigham and Women’s Hospital in Boston, Massachusetts.

At the AAPM meeting, Dr. Watson spoke during a session titled Value-Based Care for Pain Medicine and cited Harvard Business School professor Michael Porter’s definition of value in healthcare as the health outcome achieved for every dollar spent. Dr. Watson noted that payers usually focus on reducing costs and do not spend enough time considering clinical implications.

However, he said payers and all parties in healthcare should understand that if they measure clinical outcomes and improve the value of care, everyone would benefit in terms of better care and lower costs. Dr. Watson said that even incremental improvements in outcomes or costs can have a significant and meaningful impact. Still, he emphasized that the clinical outcomes should be measured depending on the condition, while the costs should refer to the total costs for the full cycle of care, including the cost of the physician visit, medication, procedure, and physical therapy, as well as time away from work.

Electronic Health Tools

Robert N. Jamison, PhD, a psychologist at Brigham and Women’s Hospital, followed with an overview of electronic tools that can be used to measure pain. Dr. Jamison said electronic data entry is preferable to paper data entry.

Twenty-five years ago, Dr. Jamison gave his patients paper to record their pain on a 1 to 10 scale on an hourly basis for 2 weeks. In the 1990s, he switched them to a handheld Apple Newton device to record their pain.

Now, as the size and costs of the electronic devices are decreasing, more psychologists and doctors are using them to assess pain. The devices can also store more information (they typically store a terabyte of data or a year’s worth of information), and the increased adoption of wireless networks makes it easier for people to access the devices.

Dr. Jamison described a concept called “hovering” in healthcare, in which patients are followed outside of their office visits or typical encounters with physicians or nurses. Although hovering may allow for more extensive tracking, it is also expensive and maintaining contact is difficult over time.

He then discussed the Pain Assessment Interview Network and Clinical Advisory System (painCAS) that provides a computerized live interview and includes a summarized assessment of pain. The painCAS is a standardized patient self-administered assessment and set of questions that inquires about patient demographics, previous medical history, pain type and characteristics, and psychiatric history, and provides a substance abuse risk assessment. When the assessment is completed, it is sent to treatment centers, integrated with electronic medical records, and analyzed by clinicians.

Smartphone applications in healthcare are becoming more prevalent, as well, according to Dr. Jamison. They are used for chronic pain assessment, medical management, psychological approaches, and rehabilitation. He added that Harvard University is developing an application for pain management that is compatible with >90% of smartphones and tablets throughout the world. The application will track, update, and modify treatment plans for patients, suggest behavioral changes, and provide relevant, context-sensitive prompts and messages.

“[Applications] are going to be the future,” Dr. Jamison said.

Quality Measures in Healthcare

If healthcare professionals are to succeed at keeping costs down and improving care, they need to embrace the shift from volume-based care to value-based care, according to Linda Van Horn, MBA, president and chief executive officer of 21st Century Edge, a healthcare consulting company. She cited Michael Porter’s belief that the goal of value-based care is improving the safety, timeliness, effectiveness, equity, and patient-centeredness of care while reducing the per member per month cost.

In recent years, the healthcare industry has moved in the direction of paying for outcomes and value rather than for each service, having integrated rather than fragmented delivery systems, employing a collaborative rather than a competitive work environment, and emphasizing evidence-based medicine rather than having unnecessary or marginal treatments that could cause harm.

However, a few initiatives are trying to keep the volume-based system intact, according to Ms. Van Horn. For instance, she mentioned the consolidation of hospitals and physician practices, the acquisitions of physician groups by hospitals, and accountable care organizations (ACOs). She said she is concerned that there will only be a few ACOs with power, creating monarchies or oligarchies that will increase costs. Still, she added that payers must encourage providers to utilize evidence-based medicine, clinical decision support tools, predictive modeling, and preventive care.

Through her discussions with payers, Ms. Van Horn found they are most interested in improving the quality of care, although she mentioned there is a need for standard definitions for quality. As of now, payers are using various definitions from organizations such as the National Quality Forum (NQF), the Physician Quality Reporting System (PQRS), and Clinical Quality Measures (CQMs).

The NQF system measures symptom status, functional status, and emotional status, and measurements are taken throughout an episode of care, from the time patients first become sick until their last treatment and/or discharge. The PQRS uses NQF measures and allows physicians to receive an additional 0.5% of their Medicare payments in 2013 if they report their quality measures. If they fail to report those measures this year, providers will be penalized at a rate of 1.5% of their Medicare payments in 2015. Ms. Van Horn said that the problem with PQRS and CQMs is that payments are based on reporting the quality measures, but not for improving quality.

To emphasize the importance of measuring outcomes and costs, Ms. Van Horn discussed the Hawthorne Effect, a psychological concept that found people will change their behavior when they are observed and have their actions and behaviors monitored and measured.

Ms. Van Horn said she empathized with a physician in attendance who, working in private practice, has had to have an employee spend 1 to 2 days per week entering data, which costs a lot of time and money. Ms. Van Horn agreed with the physician’s assessment and added that the cost of care does not typically include additional administrative and financial burdens on private physicians.

“It is getting difficult for [small private physician practices] to survive,” she said.

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