Are Value-Based, Whole-Person Healthcare Reforms Working?

Signed by Barack Obama in March 2010, the Patient Protection and Affordable Care Act (PPACA) tasked the Centers for Medicare and Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (CMMI) with improving the Medicare and Medicaid health care delivery and payment systems. One fundamental transformation necessary to carry out these improvements would be an increase in system efficiency, and this led to numerous initiatives and possibilities.

The secretary of Health and Human Services was given broad authority, following the approval of the PPACA, to expand any program that had promise in these areas without congressional approval. CMS began acting like a venture capitalist firm, looking for innovation and funding it, expanding it, investing in future potential as a strategy for scaling up. A “Triple Aim” was identified: “better health, better health care, at lower cost through quality improvement.” A vision emerged of a health care system that would reward payment for quality rather than merely quantity, value over volume.

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 has supported Medicare’s acceleration of value-based purchasing of health care for Medicare enrollees. One example of this is CMS’ Hospital Value-Based Purchasing program, in which Medicare’s payment system rewards providers for the quality of care by adjusting payments to hospitals based on the quality of care delivered. With Medicare ahead of Medicaid’s learning curve and far more streamlined, many point to these Medicare reforms as a relatively simplified – some might say oversimplified – blueprint for the more-complex Medicaid delivery system.

How does any of this translate at the practice level? In large part, particularly for many small and specialty practices, it hasn’t…yet. But as the fog clears, the shapeliness of the terrain that is emerging, at least in theory, is one involving significant forms of cross-silo integration between historically fragmented provider types, driven at least in part by alternative, value-based payment methodologies. The “patient-centered medical home” model places primary care as a hub in the center of an integrated system of care with clear standards for practice that promote whole-person strategies in care. Many primary and acute care practices are now embedding behavioral health professionals into their clinics. Increasingly, even behavioral health agencies are choosing to become medical home hubs, co-locating primary care physicians. Yet many practices struggle to implement integrated care, and value-based contracts are still relatively few and far between.

A person’s health is affected by genetics, environmental factors (such as housing, employment and other socioeconomic factors) and personal behaviors (such as diet, exercise and substance abuse). Whole-person care requires paying attention to all of these factors more effectively, connecting patients with resources outside the clinic and thereby addressing “non-clinical” social determinants of health. Whole-person care also mitigates the dividedness between behavioral health care and medical care.

In the best case scenario, transforming practices will implement protocols to increase bidirectional referral pathways between physical and behavioral health care; engage in robust, meaningful, and measured integrated care practices; improve practices which target, treat, and track both chronic behavioral and physical health conditions; enhance transitional care for shared patients coming out of acute care settings; ensure proactive, collaborative care plans that will result in diversion of shared patients from emergency services and hospitalization related to behavioral health; and work to systematically improve ways that they identify and address social determinants of health.

We are in the midst of healthcare systems reforms that will increasingly demand changes in the way services are funded—changes that better reward value over volume, incentivize advancements in population health strategies, and improve both the quality of health care and the experience of patients. Clinics implementing small, targeted changes are often pleasantly surprised to see constructive practice transformation take shape; many remain daunted by the harried pace of and skeptical of the motivations driving ever changing practice expectations as time wears on.

The end game for practices in a transformed system is insufficiently clear, yet it is clear enough that we are moving toward a system which will incentivize an increase in the implementation of evidence-based, integrative and patient-centered practices that enhance clinical quality, reduce unnecessary costs, result in increases in achievement of standardized population health metrics and improve patient experience of health care. Effective whole-person healthcare helps patients achieve optimal conditions of physical, mental and social well-being by creating robust, integrated communitywide systems of care that enhance the patient experience of care, improves the health of our citizens and population overall and reduces the per-capita cost of healthcare. That is a bold and constructive vision.

Healthcare may or may not be in the midst of one of those rare paradigm-shifting turning points described by Thomas Kuhn in his 1962 book, The Structure of Scientific Revolutions. Kuhn wrote about “shifts” – “tradition-shattering complements to the tradition-bound activity,” which are “difficult and time consuming…[and] also strongly resisted by the established community” (p. 6-7). With broad political will to fund mass-scale systems transformation, perhaps now is as good an opportunity to turn visions of integrated, whole person care into reality as we are likely to have.