Imagine for a moment a woman with a pain in her leg. She
goes to see her doctor, who orders a battery of tests. The results aren't
conclusive, but the doctor hands her a bottle of pills. The medication doesn't
bring any relief, so the woman returns to the doctor. He prescribes a second
medication; this one doesn't work either.
Then the doctor sends the
woman to a specialist. The specialist also orders a half dozen tests, some of
which the woman had already undergone. The results are again inconclusive, but
the surgeon recommends surgery. The woman goes under the knife. Three months
later, she's still in pain.
This is not how anyone wants the healthcare
system to work. It's time consuming. It's expensive. And ultimately, it's
ineffective. But this is how the U.S. health care system has traditionally
operated. Practitioners make more money for performing more procedures,
regardless of how effective they are.
That's changing. We're slowly
converting to a system that rewards practitioners for what really matters --
helping patients get, and stay, healthy. This model is referred to as
"value-based care” and the focus is on the patient: what does she need? What is
the most efficient and effective way to help her meet her goals? Is she
satisfied with the results?
It all starts with the patient. The
physician is incentivized to take the patient's perspective and look at her
So what does value-based care look like in
Patients are empowered. Patients fully
understand all aspects of their care, from diagnostic tests to treatments and
are able to make informed choices.
coordinate. Doctors and nurses share information, test results and insight
into patients' health, allowing patients to skip redundant tests or ineffective
The focus is quality. Patients see
improvements in quantifiable metrics, such as cholesterol levels or blood
pressure. Patients report being satisfied with their care, not frustrated by
Employers and patients save
money. Not only do employers spend less on healthcare premiums, but they
benefit from having healthier, more productive employees.
Increasingly, providers are forming “accountable care organizations” to
provide value-based care. These groups strongly encourage providers to
coordinate all aspects of a person's care. Doctors and nurses must communicate
with their colleagues to be sure that patients are receiving the care they need
-- and not repeating tests or procedures that have already been performed.
It's also important to understand what value-based care is not. It's not
insurance companies telling providers what to do or rationing out care. It's
not withholding service. It's not saying, 'You can only do this and not that.
Doctors make those delivery decisions."
The crucial component of
value-based care is quality. To analyze the quality of care, Premera looks at
discrete metrics -- test results and screening levels-- but also bigger
questions. Are patients getting better? How often are patients rapidly
readmitted after being released from the hospital? Do patients leave the
hospital with a clear plan for follow-up care?
Over the past several
years, Premera has emerged as a leader in value-based care. We really launched
a different way of doing business in 2011 by inserting measures and metrics
into global outcome contracts. The company began tying reimbursements to
quality and cost effectiveness. Premera then began working with two dozen
hospitals to improve quality. Now the company is talking with provider groups
about what is important to them -- and their patients -- and how to improve
While it's still early to evaluate the success of these efforts,
what is clear is that all parties -- Premera, providers and patients--
recognize the benefits of coordinated and effective care.
certainly be guided by results, whether they're financial or quality
measurements. This has to be a long-term effort and we have to take the long