Abstract
Value-based medicine is that system of healthcare delivery that rewards providers and hospitals for providing the highest quality of care at the lowest possible cost. 1 At first glance, such a definition is not at all original. After all, is the provision of the highest quality of goods or services at the lowest possible cost not the goal of any business? Why should medicine have been any different?
To answer this question, it is necessary to examine separately the two elements that constitute value-based medicine: Quality and cost. Let us first consider the question of quality. Historically, compensation for medical services has been primarily, if not exclusively, volume-driven. The greater the volume of the goods or services provided, the greater has been the reimbursement. Quality never played a central role in such a system, if it played a role at all. In fact, even if the volume of services becomes so great as to compromise the quality of care provided, reimbursement may continue to rise. It has taken a substantial amount of time for medicine to catch up to Charles Mayo's astute and prescient observation: “Public demand is the only true stimulus for tradesmen and professional men alike.” 2
Medical practice is a business. It is subject to the same market forces as any other business, be it a trade or a profession. In a free market system, Adam Smith's “invisible hand” of open competition should lead to its domination by those businesses that offer the highest quality of goods or services at the most reasonable price. What has protected medical practice from the forces of the marketplace for so long has been a lack of transparency. Today, transparency is at long last entering into the world of medicine. With transparency comes accountability. The public at large and payers, in particular, are now capable of seeing and measuring the quality of care being offered by providers, hospitals, and other healthcare organizations. It is inevitable that the public will expect and demand quality of care in exchange for the cost such care involves.
Cost is the second element of value-based medicine, and it is cost that has led to a special urgency in changing the model of healthcare financing in the United States. According to the World Health Organization, the United States ranks only 37 on a list of 191 in terms of overall health care performance. 3 Yet the United States, the most affluent nation in history, spends more than any other nation in the world on health care. It is estimated that 16.6% of the GDP currently goes into health care. By 2018, it is anticipated that this percentage will rise to an unsustainable 20.3%. 1 Clearly the traditional model of volume-driven medicine has served the nation poorly.
The question then becomes what strategies can be implemented to control costs while at the same time maintaining or even improving upon the quality of care delivered. The answers lie in addressing two issues. The first is who will be responsible for paying the bills, a subject for a later day. The second issue is to decide how those bills will be paid. This is where value-based medicine may play a critical role.
The drive toward value-based medicine comes from players in all sectors of society. 4 Employers and employer-based organizations such as the Leapfrog Group have played a leading part in this process, as has the insurance industry (i.e., pay for performance contracts). Non-profit organizations like The Joint Commission, the National Quality Forum, and the National Patient Safety Foundation have championed the cause of transparency in medical performance. Medical organizations have also become engaged. The American Medical Group Association, for example, has been instrumental in creating the concept of the Accountable Care Organization (ACO), which will point the way toward a system of healthcare reimbursement based on high quality of performance and cost savings. And, of course, the U.S. Government has become involved as well, as evidenced by enactment of the HITECH Act and the Patient Protection and Affordable Care Act. Whatever the fate of healthcare reform, it is readily apparent that because of its broad base of support, the concept of value-based medicine is here to stay.
But how can this concept be applied to breastfeeding promotion and support in the setting of medical care? Can we find examples already in play? The answer is yes. Perhaps the best example relates to the obvious premium that value-based medicine places on preventive health. It is preventive health that offers the best chance of ensuring a high quality of life because patients are always healthier if diseases can be prevented rather than simply treated or managed. Preventive medicine is also more cost-effective for the same reason: Prevention is as a general rule less costly than treatment or management. In light of this, it should not be surprising that the Affordable Care Act 5 requires all health plans to cover those preventive health services listed in the American Academy of Pediatrics publication, Bright Futures; among those services is breastfeeding counseling. 6 This development is highly significant because it involves a paradigm shift away from the “evaluate and treat” approach, which acknowledges breastfeeding only to the extent that it becomes pathological, to a far more positive model of wellness promotion. Such a model recognizes the value of breastfeeding and its support. It will afford medical providers a hitherto unavailable opportunity to partner with the families they serve in promoting their health and enriching the quality of their lives.
An important part of value-based medicine concerns the creation of quality indicators, because “what gets measured gets managed.” 7 Quality indicators for breastfeeding support are already emerging. Both the National Quality Forum and The Joint Commission have endorsed the outcome indicator of exclusive breastfeeding at hospital discharge. In addition, a set of process indicators may well emerge from the Centers for Disease Control and Prevention's Maternity Practices in Infant Nutrition and Care survey parameters. These indicators could eventually serve to assess the quality of maternity services provided to breastfeeding infants and their mothers and by means of such an assessment determine how much the healthcare facility should be reimbursed. Through quality indicators, providers of medical care will be held accountable for their performance in the promotion and support of breastfeeding. An excellent opportunity for the creation of breastfeeding-related indicators has been provided by the Children's Health Insurance Program Reauthorization Act (CHIPRA). Under CHIPRA, 100 million dollars has been allocated for a joint project involving the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality to create a set of quality indicators specifically relating to the pediatric population. It is important that breastfeeding promotion and support be given the highest priority because breastfeeding is, or should be, the quintessential primary care issue. In the not too distant future, these quality indicators will find application in many areas, including pay for performance contracts, National Committee for Quality Assurance (NCQA)–certified Medical Home Guidelines (Standard 3: Care Management), “meaningful use” clinical quality measures in electronic health records (EHR), and conceivably CMS-administered value-based purchasing.
Another excellent example of applying value-based medicine to breastfeeding support relates to the NCQA-certified medical home. The NCQA guidelines for accreditation offer several opportunities to integrate breastfeeding management into medical practice, with incentives for providing high quality of such care. 8
Under HITECH, providers will be given financial incentives for qualifying as “meaningful users” of EHR. Meaningful use can significantly improve upon the quality of care given to breastfeeding mothers and infants. For example, “meaningful use” requires that EHR systems possess the “capability to exchange key clinical information…among providers of care and patient authorized entities electronically.” 9 Many areas of care can become involved with the breastfeeding newborn and his or her mother, such as the maternity ward, the delivery room, the special care nursery, the house staff, the obstetrician, the pediatrician, pharmacy, the Women, Infants, and Children office, a lactation consultant, the insurer, and perhaps under certain circumstances even the emergency room or specialists for infants with special healthcare needs. How is care to be coordinated, unless reliable, accurate, and up-to-date information can be shared rapidly and in a manner that protects the rights of the family to confidentiality? “Meaningful use” should go a long way in ensuring such seamless and highly integrated care.
Opportunities for breastfeeding promotion may also exist in the pediatric ACO. Through the pooling of resources and collaborative efforts involving providers, hospitals, and perhaps local resources and medical specialists, the ACO might greatly facilitate the creation of community-based lactation centers and peer counselor programs. Another benefit of the ACO is that breastfeeding catastrophes such as hypernatremic dehydration and severe hyperbilirubinemia (possibly complicated by kernicterus) will potentially become “sentinel events” and “never events,” to be monitored by such regulators as the CMS and The Joint Commission. 4 The occurrence of these events can result in substantial financial penalties for the medical organization assuming responsibility for them—in this case the ACO. It is therefore in the interest of the ACO to implement policies and procedures to prevent such eventualities from ever happening. Perhaps for the first time, we will no longer have to deal with a catastrophe after the fact, as an isolated incident that could not be prevented. As a systems problem, it becomes very preventable.
Finally, one other promising application of meaningful use should be mentioned. The CMS rules of the Incentive Program governing EHR meaningful use (Stage 1) deal with six medical practice outcomes, one of which is to “improve population and public health.” 10 Although the current objectives for meaningful use qualification do not specifically relate to research, it is entirely conceivable that research could at some point in the future become incorporated into the “population and public health” goal. The American Academy of Pediatrics explicated on the research potential of medical home-based EHR systems in a recent policy statement: “Finally, as a potential source of ongoing accrued clinical data, medical home information systems must…pool data from individual medical home information systems (to health information exchanges) for public health research and planning at community and population levels.” 11 To date, reliable epidemiological studies seeking to draw associations between breastfeeding practices and health outcomes have been limited by stationery, postage, and other budgetary considerations. In addition, the data generated by these studies are derived from the recall of the subjects involved, which may or may not have been reliable. Application of the “population and public health” goal to research would allow for the recruitment of a virtually limitless number of subjects. The data would come directly from the medical records, and subjects could be followed prospectively, greatly enhancing the value of these studies. At last, it may be possible to link breastfeeding to health outcomes by means of studies of sufficient power hitherto deemed impossible, thanks to meaningful use of EHR.
The evolving model of value-based medicine offers great promise for breastfeeding promotion and support. However, if opportunities are not actively sought out and cultivated, the prospect of integrating breastfeeding management into primary care medicine may be lost for many years to come.
Disclosure Statement
No competing financial interests exist.