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October 9, 2019

Disappointment in the Value-Based Era: Time for a Fresh Approach?

Author Affiliations
  • 1Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 2Department of Medicine, Harvard Medical School, Boston, Massachusetts
  • 3Harvard Global Health Institute, Cambridge, Massachusetts
JAMA. 2019;322(17):1649-1650. doi:10.1001/jama.2019.15918

Over the past decade, there has been a series of national initiatives to improve the quality of care that people in the United States receive, many of which originated from the passage of the Affordable Care Act in 2010. However, the evidence to date suggests these efforts have had limited beneficial effects in the Medicare population. Key programs, such as the Hospital Value-Based Purchasing Program, the Physician Quality Payment Program, and the US Hospital Acquired Condition Reduction Program, have not improved patient outcomes. The Hospital Readmissions Reduction Program initially seemed to have reduced hospital readmissions, but more recent studies suggest that much of the gains may be due to changes in coding, not changes in clinical practice, and it remains controversial.1 Furthermore, some studies have raised concerns that the policy may be associated with higher mortality rates as hospitals aimed to decrease readmissions among patients who have illnesses that may need the care, although other studies have not demonstrated an association between the policy and mortality.2-4 Two other major efforts, the program on accountable care organizations (ACOs) and bundled payments, have shown promise on reducing costs, but neither has had large effects on quality.5 Nearly a decade after the Affordable Care Act, the evidence is in and is sobering. It is time to leverage the evidence to take a fresh approach to improving the quality of care for patients in the United States.

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    1 Comment for this article
    An Alternative Conceptual Framework
    James Mold, MD, MPH | Emeritus Profesor of Family and Preventive Medciine, University of Oklahoma
    While I don't disagree with focusing attention on high complexity, high cost patients, I believe that we need a new perspective on health and a new conceptual framework for health care. The answer to better, and less expensive care for all patients, I believe, is prioritization of interventions based upon patient-relevant goals and priorities. I have explained this approach in the following article: Mold J (February 21, 2017) Goal-Directed Health Care: Redefining Health and Health Care in the Era of Value-Based Care. Cureus 9(2): e1043. DOI 10.7759/cureus.1043.
    CONFLICT OF INTEREST: I have a financial interest in a book on this topic published by Full Court Press.