Value-based care and the resulting payments based on meeting quality measures is a relatively new model to supplant fee for service (FFS), but it’s growing in popularity among payers and providers. In a recent survey of 102 healthcare executives, half said value-based payment will be the dominant revenue model in the next five years and the majority already had at least 25% of their revenue tied to value-based payments.
We examine how the concepts of value-based care and evidence-based medicine (the dominant mode of clinical practice) intersect. Specifically, what role does evidence play in the provision of and reimbursement for value-based care?
What is value-based care?
Michael Porter and Elizabeth Olmsted Teisberg defined value-based care in their 2006 book, Redefining Health Care. The premise is relatively straightforward: Physicians and nurses who deliver the most “value” per dollar of healthcare cost should be rewarded. Today, The Centers for Medicare & Medicaid Services (CMS) defines value-based care as programs that “reward health care providers with incentive payments for the quality of care they give to people with Medicare or Medicaid.”
Under FFS payment models, healthcare physicians and nurses have incentive to prioritize quantity over quality—whether or not they exploit this inducement. The more patients a provider sees, the more they can bill. But the passage of the Affordable Care Act (ACA) in 2010 brought change and introduced a number of programs and incentives aimed at encouraging providers to focus on quality over quantity in medicine.
In short, a value-based care model pays healthcare providers based on how much their patients’ health improves. So how can providers and payers tell whether a patient’s health has improved? That’s where evidence-based care standards come into play.
What is evidence-based care in medicine?
Think of value-based care and evidence-based care as complementary care models. Value-based care seeks to maximize the “value” provided to a patient per dollar spent in cost but requires a way to quantify that worth. Value, of course, can be imprecise. As a result, healthcare payers and providers alike require an evidence-based, multi-factored approach that brings forth empirical data on outcomes for quality measurement and improvement.
The scope of evidence-based healthcare
An evidence-based care model uses clinical expertise, data, and research to determine the best way to treat patients for a specific disease or condition. Evidence–based care also considers patient values and circumstances, and that includes social and cultural factors (e.g., social determinants of health). We use evidence-based care in medicine for wide-ranging outcomes, from reducing hospital-acquired infections to applying precision medicine techniques that use genetic research and genomics, Specifically, evidence-based healthcare includes the following activities:
- Research that produces the evidence. Research is the backbone of evidence-based care—and generally of all high-quality healthcare. Research’s goals can be twofold: it can generate new knowledge and/or validate existing knowledge. Consider the evolution of an ages-old medical procedure such as trepanation. It was largely based on theory when it was introduced, and it soon became clear that the theory behind trepanning was valid. But at the time, medical professionals could not document for certain why it worked; they only knew that it worked. The research process was invaluable in explaining the why and, as a result, the procedure is still used today (albeit with some upgrades).
- The application of the evidence. Once evidence is compiled, it’s applied in a clinical setting. Evidence-based clinical practice relies heavily on research to ensure that physicians and nurses are making the right patient-care decisions for their patients’ needs. Research and evidence-based clinical practice each need the other to be effective: without research, new information is not applied to patient care, and without evidence-based clinical practice, it can be difficult to perform further research on a particular form of care to measure its effectiveness.
- Evidence-based policymaking, purchasing, and management for health services. Evidence also plays a key role in policymaking, spend management, and supply chain management/purchasing decisions. An evidence-based clinical care model delivers holistic value but requires timely access to unbiased clinical data and benchmarked data. It assesses the clinical, operational, and financial impact of each procedure, service, technology, etc., under consideration with thorough, evidence-based analysis. It often guides healthcare leaders to make the right decisions on what policies and protocols to put in place, what purchasing decisions to make, and how to manage the overall system over time to best meet patients’ needs and organizational goals.
What is evidence-based practice (EBP)?
Notably, an evidence-based care model is not the same as evidence-based practice (EBP). While evidence-based clinical care models are mostly concerned with the overall system in which physicians and nurses operate, evidence-based practice is mainly about how individual providers do their jobs, using both research and their clinical experience to make the right clinical decisions for each individual patient.
All of this ties into how value-based care is delivered, both in terms of the overall system and how providers practice.
What’s the difference between research and EBP?
Research is a specific and rigorous process aimed at discovering new information or validating existing information in a broader sense. EBP, on the other hand, uses existing data to make the right patient-care decisions in a clinical setting.
For example, EBP draws on existing data to ensure certain infection-control policies are followed, whereas research might be used to find out why those infection-control policies are more effective than others.
What happened before EBP?
Before EBP, most physicians relied on intuition and their professional experiences to inform care decisions. That began to change in medicine in 1972, when Archie Cochrane—widely recognized as the father of EBP—published his book “Effectiveness and Efficacy: Random Reflections on Health Services.” In the book, Dr. Cochrane asserted that most clinical decisions providers made were not based on research or systematic reviews of clinical outcomes, but by intuition—which meant that the quality of care delivered to a patient often varied widely depending on the provider.
Dr. Cochrane’s book recommended that clinical researchers collaborate internationally using randomized control trials (RCTs) to perform systematic review of clinical practices and determine whether the practices commonly accepted as the “best” were, in fact, the best available ways to deliver patient care.
What kind of research is used in EBP?
Evidence-based practice relies on quantitative and qualitative research studies. Quantitative research in medicine is data-driven, looking for correlations between different variables within a given dataset to determine how (or if) those variables are related. Qualitative research tends to look more closely at the meaning of those variables and at how the variables themselves are created.
For example, quantitative research can be used to link obesity and an increased risk for type-2 diabetes, simply by comparing the numbers. Qualitative research, on the other hand, would be used to explain why obesity occurs in the first place by learning more about the life experiences of obese patients with type-2 diabetes. Qualitative research has played a key role in our understanding of things like social determinants of health.
In research, publication doesn’t guarantee quality
As noted, research is meant to be a rigorous undertaking. Ideally, all research studies would be required to satisfy a series of factors before they could be considered valid and published; unfortunately, that’s not always the case. Some forms of research—known as “blue-sky” research—are useful in their own way, but should not be applied to clinical practice (and are not meant to be).
But even where clinical research is concerned, study quality varies widely in medicine. If the study is poorly designed, or undergoes no systematic review, its conclusions can’t be trusted. In others, the data may not fully support the conclusions. Physicians, nurses, and healthcare leaders should never assume that a study is valid just because it has been published.
How does EBP benefit providers and patients?
EBP benefits providers and patients in a variety of ways. From a provider standpoint, the evidence-based clinical care model creates a baseline for what providers should do according to the patient’s situation and individual health needs. In other words, providers need not determine from scratch how to treat each new patient with a given condition. The clinical care model uses existing evidence to lay the right groundwork for that patient’s care, so clinicians and staff can get things set up quickly before the physician and nurse is involved.
EBP also helps providers avoid tunnel vision when it comes to patient care. As this example points out, many providers were encouraging expectant mothers to induce labor prior to 39 weeks gestation for the comfort or convenience of the mother. However, studies showed that inducing labor before 39 weeks often led to more problems for the newborns, including an increased need for ventilators. So even if none of a provider’s patients experienced post-birth complications, the evidence can still be used to show the provider the risk of inducing early, informing them how best to treat their patients.
This, of course, benefits patients in a variety of ways. Patients don’t have to worry whether they are receiving the right care for their needs, because the provider’s clinical decisions have been rigorously researched and are supported by significant amounts of data. EBP also gives patients a greater degree of flexibility and choice over their care or treatment, because they’re not limited just to what the provider’s intuition or experience tells them is the best approach. Providers can offer patients a number of evidence-based treatments and allow patients to choose the one that is the right fit for their needs.
How does EBP support value-based care?
To demonstrate how EBP supports value in healthcare, let’s return to our earlier example of diabetes. We know that obesity can lead to type 2 diabetes, which can in turn lead to heart and blood vessel disease, neuropathy, kidney disease, and a host of other complications—and treating each of these complications carries a cost. The more of these complications and comorbidities a patient can avoid, the more value a payer receives for the cost of the patient’s primary care.
Providers in turn can use modern, effective strategies that guide and empower patients and members to control their health plan by accessing information, utilizing self-service applications, and receiving care on their terms. Compared with pre-pandemic care, consumer behavior has significantly changed, with a massive shift and emphasis on digital channels and self-service. EBP supports value-based care by encouraging providers and patients to meet goals, which helps providers meet quality targets for reimbursement. Along the way, providers apply existing research to clinical decisions, helping providers pinpoint the right approach to help patients avoid serious—and costly—health issues.
EBP is a crucial part of value-based care not just because it allows healthcare providers to effectively treat and manage their patients’ conditions based on data that has undergone systematic review. From an organizational standpoint, it helps healthcare leaders to use clinical evidence to provide the best possible support to their providers through purchasing, policymaking, and management. By using EBP to support a value-based care delivery model, healthcare organizations can gather the information they need to deliver for their providers, clinicians, and their patients.
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