Introduction to an thought I’ve been having. Value Care is hot right now. Gone are the days of old, paternalistic ideas like Fee for Service. Along with terms like Patient Centered, Value Care is the new hip idea in healthcare. Medicaid Directors across our nation, insurance companies, hospitals, and even us patients want Value Care instead of Fee for Service. Makes sense, no one wants to pay for crap and crap is exactly what we have started to pay for with these old ideas. That said, what does Value Care actually mean? 

As a long time chronic patient, I have a good idea what provides me with value in my own healthcare. However, I’m just one person who isn’t a accurate representation of all chronic patients so I googled the term “Value Care” looking for a more universal definition. Google defined Value Care as “a payment model that rewards healthcare providers for providing quality care to patients. Under this approach, providers seek to achieve the triple aim of providing better care for patients and better health for populations at a lower cost.” Not sure I understand what all those words mean but they sure sound like a positive, right?!

Just for fun and as a quick reference, I also asked the Google what Fee for Service meant. Google returned Wikipedia’s definition as  “a payment model where services are unbundled and paid for separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care.” I will be honest, the phrase “quantity of care” is scary but I will give it credit, Fee for Service was the “it” model and was the best idea most had for many years. It also makes sense based on what I learned in all of my economic and finance classes at Boise State University, services are supposed to be paid for as we (consumers or patients) use them.

Defining Value Care using the porn test. In 1964, United States Supreme Court Justice Potter Stewart, in an attempt to develop a test for obscenity in Jacobellis vs Ohio, famously said “I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description "hard-core pornography", and perhaps I could never succeed in intelligibly doing so. But I know it when I see it, and the motion picture involved in this case is not that.” Unfortunately for Value Care, quality of care is very similar in definition as the Supreme courts definition of porn, “I know it when I see it’. Does this really mean that the measure of value in my healthcare is the same the one courts use to define porn? How can that possibly be right? 

Ok, so lets approach the idea of Value Care from a different perspective, as a Director of Medicaid. More specifically, I will pretend that I’m my home state of Idaho’s Medicaid Director. As we all know, CMS (Medicare, Medicaid, and CHIP (Children’s Health Insurance Program)) are the largest payers in healthcare today which gives me a ton of power and influence in defining Value Care for the state. 

Idaho’s annual budget, for simplicity sake, is $4 billion a year. Of the $4 billion, roughly 30% or $1.2 billion is allocated to Idaho’s Department of Health and Welfare. For simplicity sake, lets assume $1 billion is allocated to Medicaid of which $600 million is marked for spending on hospital reimbursement in Idaho. For you math wizards, that means in Idaho, hospital reimbursement accounts for half of the budget of Idaho Health and Welfare alone. 

30 second hypothetical. Let’s say that in 2018 Idaho gave millionaires and billionaires (yes Idaho has a couple of billionaires) a personal income tax cut. This has resulted in a $50 million reduction in actual revenues per month than was projected for 2019. The governor, being a self-declared champion of conservative ideology, orders an immediate reduction of spending for all state agencies. As Director, it makes sense that I cut hospital spending in order to comply with the governor’s order. After all, hospital spending is the largest piece of the Medicaid budget by far. 

If I were to cut 10% from hospitals that is an extra $60 million that is immediately available towards Idaho’s budget shortfall. This means the governor only has to cover the $50 million monthly reduction for 11 months now, Medicaid has done its part. Like it or not, as Director of Medicaid my top priority (or value) has to be acting as a fiscal intermediary for Idaho taxpayers which means I need to be a good steward of its money (politically in Idaho that means a highly conservative steward). Helping to prevent a budget shortfall ensures Idaho Medicaid can continue to operate without further cuts to other programs while still providing care to its most needy of residents. Yes, $60 million is a large amount of money but spread evenly over Idaho’s 50 plus hospitals that only means a reduction of payment of just over $1 million per hospital. Or I could reduce a hospital’s reimbursement amount based on Medicaid usage. This would reduce the cuts to hospitals in rural Idaho while bigger hospitals in areas like Boise (they see less Medicaid patients as a percent since a higher portion of its population already has health insurance compared to rural areas in the state) take a larger hit. Hospitals in Boise reported patient revenues of over $1 billion each for 2017 so a reduction in their Medicaid reimbursement won’t affect them as much in theory. As Director, isn’t this providing value to Idaho taxpayer’s along with still providing value (in this case the measure being continued access to healthcare) to its members. 

One last perspective, Value Care through the eyes of patients like myself. First, lets use data ownership as an example since clinical trials are the new “it” thing in patient advocacy. 

I am of the belief that any data created by my heart, weight, height, X-ray, or blood for example, is mine. I own this information, not the institute conducting or storing the measurement of my data. Control of my data should be as easy and convenient as the app on my phone which lets me control my finances. Not only do I want control, I want my health information to be stored in an safe and secure data exchange so if I go skiing in Sun Valley over Christmas break and tear my ACL, I want the doctors there to be able to access my medical information within seconds since I am a chronic patient with multiple issues. 

As we all know, the type of technology I’m talking about is incredibly expensive. Personally, I can’t afford to buy this type of technology on my own. I need my government to float the bill for this tech, which benefits all citizens in the state, for the time being. It is the only entity with the power to both buy the necessary infrastructure while at the same time being a central authority to ensure access for all (even those with small or no checkbooks). Hopefully, someone soon will design a patient centered, value care type EHR which is both secure yet highly accessible by all of my healthcare team and to all of my chronic friends who have less financial resources than I do. 

Another example of value care from my perspective. In 2014, I had my right hip replaced at a local hospital. The orthopedic wing of my hospital had its own personal chief just for its orthopedic patients. I ate well while at the hospital for my surgery. Since hospitals are notorious no sleep zones, a clean, nutritious diet added value to my care. Simply put, food heals. In my expert chronic patient opinion, all wings of hospitals should have their own personal chief trained to feed patients with a particular disease or condition. The fast food model of dieting might work in a market economy but not in patient care. Yes, this method of feeding patients is more expensive than getting food from the King or Colonel for example, but shouldn’t my quality of life be more important than an income statement or hospital balance sheet. 

Also, if Medicaid hospital reimbursement helps ensure hospitals have chiefs for all its wings shouldn’t the governor look to other areas of the budget to cut because this piece of the pie of taxpayer money is adding value to all. After all, public health is part of any hospitals mandate or mission statement. We know, without a doubt, that proper nutrition equates to better health outcomes for all. We also know that the healthier a society is the better educated it becomes. Doesn’t this sound like case for more hospital spending by states, not less?

Conclusion. Simply put, for the moment Value Care is like porn, we can’t specifically define it but we know it when we see it. As a chronic patient, that stings. How might we change this? I believe the answer has to start with both a national and local conversation about Patient Value payment models, not Value Care payment models. We need specific payment models that improve the “quality of life” of patients because definitions like “quality of care” can mean to many different things that change drastically depending on perspective.

If President Trump or Senator Rand Paul are on the ideologically right of healthcare spectrum and Senator Warren or Sanders are on the left, we need a new spectrum revolving around patient stories like mine. We need chronic patients involved in local campaigns now because there has never been more acceptance of the idea that healthcare needs to change right now. My worry is that in 20 years I will be writing this exact same post about how Value Care was the “best thinking of its time” but now needs to evolve into Patient Value payment models based on patient stories because we still can’t define Value just like we can’t define Porn until its too late.