Leaders Speak Out on Value of VBP

In the February 2012 Impact Analysis Report, Value-Based Purchasing: Facing the HCAHPS Hurdle, HealthLeaders Media Council members were evenly divided on whether VBP, as designed, will succeed in improving quality of care while also reducing costs. We asked four leaders: What is the outlook for your organization, and what are the reasons it will succeed or fail?

Scott Trott, MHA

Vice president of payer management and faculty services
UNC Healthcare System
Chapel Hill, N.C.

On the outlook for VBP:
Our outlook is good from the perspective that the patient experience component is already very high. The clinical components need improvement and we have active programs in place around all of those measures. It will succeed in the near-term based on the organizational approach of looking at this across the board for our health system.

On synergies:
We have a couple of our major commercial contracts that have many of these measures in them as well, so we have some synergy between the governmental and commercial payers. One thing that might lead to its failing is if we get focused on multiple other measures or other payer-specific measures that aren't in sync with value-based purchasing core metrics.

On incentivizing physicians:
The other part of this is keeping our physicians engaged. Another year or so of having incentives built in to help keep physicians engaged in helping to drive these changes and improve these measures and is absolutely critical. Some incentives have to be built in, maybe it's an internal thing that we need to do, where our physicians have the chance to benefit as these scores improve. 

On reducing cost of care:
I am not sure if cost will actually be reduced. So many of these clinical measures are based and predicated on folks who are in the hospital or have had an encounter, and costs are really mostly reduced when you avoid having folks come in from the beginning. This kind of value-based purchasing is focused on inpatient or acute events. 

Judy Schwartz, MD

CMO
Knox Community Hospital
Mount Vernon, Ohio

I don't think it will have an impact on quality because I don't think what they are monitoring is quality. It's more about monitoring processes than things that have been shown to improve quality.

For example, all the VTE [venous thromboembolism] prophylaxis that we are near 100% on, I am not sure that it really prevents anything of significance from a clinical perspective. Or whether or not you think to document after you tell patients they should take aspirin. Patients are already doing it so I don't think it is markedly changing what is going on. It's just improving the documentation, which of itself may be some benefit but I don't think it is much of a quality benefit as stated.

I do think it will help with service delivery. It will make everybody pay attention to that but when you look at it, those scores are already very high. On the other hand, it depends upon what area you are looking at. ED scores, for example, tend to be lower than ambulatory services scores. Inpatient is heavily impacted by what happens in the ED. So, if your ED isn't doing well, your inpatient scores can suffer from that. We are fairly comfortable here in that we don't have the huge volumes they have in large-city EDs, where they have hours upon hours of waiting times.

Marlene Weatherwax

CFO and vice president
Columbus (Ind.) Regional Health

We are an independent single-hospital health system and I believe we have a good outlook for the organization. We have strong financial statements, good results, high quality, and improving patient experience. We used to be at the top of the game before HCAHPS came into play and we are working on getting back on top.

Why would it fail? I don't know how to answer that one. We are pretty close to the Indianapolis market and there is a lot of posturing going on by the large health systems. I would contend that Indianapolis is a little overbuilt with specialty hospitals, so everybody is fighting for market share. When they have a difficult time in their own market, they start looking outward. Our pockets are only so deep, where some of their pockets are a little deeper.

I don't know that in and of itself value-based purchasing is doing anything to improve quality while reducing costs, but it is getting people to focus on these things. By using very process-oriented metrics, it is forcing hospitals to look at better types of process improvement methodologies, such as Lean and Six Sigma. I think that by going through that, they will improve their quality and costs, but I don't think that value-based purchasing as it is designed will really cause that to happen on its own. 

Gary Tiller

CEO
Ninnescah Valley Health System Inc.
Kingman (Kan.) Community Hospital

Don't call it value-based purchasing. Call it "We are going to throw you under the bus and take your money." Do I have any faith in these things? Not much. It's a ruse. First of all let's separate quality from cost. There are a thousand different interventions, séances, Kumbaya moments in quality that HHS is pushing and they are plunking down money and some of these things they have studied for years and they have not proven to be of any benefit.

The push for quality is not going to save money and it's not going to improve quality either. But they tie money to all these things.

The two things that have a chance to actually save money are the medical home concept and the evidence-based medicine, and we will never see much of those. For one thing, on the medical home, the family practice docs don't want to lose the camaraderie with the specialists, and the specialists don't want to see any of that happen. They want to see the patient get into that vortex where the specialists keep handing them off. While you may impact the rate of increase with this sort of stuff, you are not going to ever have a decrease.