Top Things to Know: Value-Based Payment for Clinicians Treating CV Disease
Published: July 10, 2023
- The quality of American healthcare ranges from exceptionally good to unacceptably poor, with worse outcomes too often occurring inequitably along racial, ethnic, socioeconomic, and geographic lines. Simultaneously, US healthcare costs are markedly higher than healthcare costs in other countries. In the traditional fee-for-service system, clinicians are paid based on the number of services provided, without financial incentive for quality or efficient resource utilization.
- Value-based payment (VBP) is considered a key strategy to improve quality and outcomes while controlling costs. The goal of VBP is to reward better outcomes, lower costs, or both, and, in doing so, encourages clinicians to improve the delivery of care. VBP programs should carefully weigh the incentives between lowering cost and improving quality of care and ensure an adequate focus on quality of care.
- Current VBP models range from fee-for-services with no link to quality or value to population-based payment models where payments are decoupled from services provided. Different categories of VBPs include pay for performance, episode-based, primary care-based, and specialty care-based.
- Quality of care is a critical component of VBP programs. Quality measures that capture both evidence-based processes of care and clinical outcomes are needed to accurately track performance. VBP programs should focus on using a limited set of measures given the administrative burden of quality measurement on clinicians and health systems; however, metrics focusing on health status and equity need to be incorporated.
- Cost measurement is also a key component of VBP. Improvements are needed in how costs are measured, the actionability of the included costs, and the timeframe measured. Also, safeguards are needed to ensure the provision of clinically effective services.
- Risk adjustment is essential for long-term success of VBP programs. While current models include medical risk factors, they do not include functional status or social risk factors, which have strong associations with outcomes. Omitting these factors creates both unfair programs and incentives to avoid high-risk patients and should be remedied. More attention also needs to be focused on data adequacy and consistency.
- VBP program design must address equity in terms of reducing unintended consequences and by including equity measures in every program. All VBP programs should be evaluated for unintended negative effects on equity during implementation. Programs that improve equity should be prioritized for broader implementation.
- The role of quality of care needs to be elevated in the design of VBP programs. Benchmarking measures and overall performance should focus on relative performance, absolute performance, or improvement over time. Absolute and improvement-based targets have advantages related to fairness and equity.
- VBP program implementation and evaluation are critical to success and, to promote actionability, should include a pre-specified evaluation plan that captures the impact on quality, cost, and equity. The equity evaluation should capture the effects on access and outcome disparities, and should determine program scaling or deimplementation.
- To ensure long-term sustainability and more ubiquitous adoption, VBP programs must find the right balance between quality and cost, recognize that equity is central to quality, promote flexible funding for comprehensive, team-based care, and engage clinicians as partners.
Citation
Sandhu AT, Heidenreich PA, Borden W, Farmer SA, Ho PM, Hammond G, Johnson JC, Wadhera RK, Wasfy JH, Biga C, Takahashi E, Misra KD, Joynt Maddox KE; on behalf of the American Heart Association Advocacy Coordinating Committee. Value-based payment for clinicians treating cardiovascular disease: a policy statement from the American Heart Association [published online ahead of print July 10, 2023]. Circulation. doi: 10.1161/CIR.0000000000001143