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A value-based payment system could revolutionize health care as we know it

The health care payment system is due for a major overhaul.

Photo: Getty Images
  • Value-based health care focuses on tangible improvements in patient care outcomes.
  • The goal is to reduce the per capita cost while improving treatment.
  • Current fee-for-service payment models focus too much on quantity and not quality of care.

Throughout the century, miraculous advances in medicine and scientific breakthroughs have brought the health care profession to a new zenith of excellency. Incurable diseases have been eradicated and conditions that were once death sentences are now vanquished with a quick pill or surgical fix.

But underneath all this progress lies a vestigial sore weighing down the entire health care industry – the limited health care financial system. While medical care and technology itself has advanced to greater heights, the underlying business and financial functions are lacking.

The mounting costs of a fee-for-service health care payment model and subsequent lack of oversight on the quality of care is becoming too much to handle for both individuals and employers alike.

A recent report from the Health Care Cost Institute found that per-person out of pocket spending has reached an all time high for Americans under the age of 65 who are covered by employer-sponsored insurance.

Data gathered from that same report shows that employer coverage has risen 44% per enrollee between 2007 and 2016. The total cost of spending on employer health care services has ballooned to an annual cost of nearly $700 billion.

What's the underlying issue for this? The problem may be endemic to a fee-for-service payment model.

Time to shift to a value-based payment system

The current state of payment systems in health care takes the form of disjointed and disparate bill of costs that don't take into account whether or not the treatment was valuable. Let's look at a simple example on why this is so.

  • Fee-for-service care - A patient undergoes surgery. They end up getting an infection. On their next visit back to the medical center the patient now bears the cost to treat it.
  • Value-based care - A patient undergoes surgery. They end up getting an infection. On their next visit back to the medical center the hospital bears the cost to treat it.

While this is an overly simplified example, it cuts to the heart of the issue. Health care services and payments need to be held accountable for what value they bring and not what laundry list of treatments they doll out.

Fee-for-service models lower quality of care and are a disservice to patients and employers alike. Michael J. Dowling, president and CEO of Northwell Health, argues that the rising costs are intrinsically tied to lower quality of care. "Value-based care ties reimbursement to quality, not quantity of care. The goal is to incentivize better care and lower costs," he writes in "Health Care Reboot".

Dowling imagines a world where the quality of care is the standard rather than the volume of care.

A lot is at stake here. Business as usual is going to be unsustainable for both hospitals, employers and individuals. For institutions like Northwell Health, clinical outcomes are paramount; health care improvement and high-quality care need to become the norm.

And patients agree. In a quest to figure out just what value-based health care means to patients and physicians, The University of Utah conducted a far-reaching survey. The results showed that patients identified a few key characteristics of high-value health care:

  • Around 62% considered the quality and effectiveness of their care to be the most important factor of high-quality health care.
  • 26% were most concerned with their out-of-pocket costs.

Major companies are already taking note and are springing into action with new plans.

Employer initiatives with value-based health care plans

Are employers doing enough for their employees?

Source: 2017 Willis Towers Watson Best Practices in Health Care Employer Survey; 2017 Willis Towers Watson Global Benefits Trend Survey, United States.

For quite some time, companies tried to cut down on costs using measures like increasing employee expenses and limiting their coverage and access to certain specialists. But now they're realizing that this is not the way to go, and are instead taking a more active role in developing their value-based health plans.

Multinational insurance broker Willis Tower Watson has found that an increasing number of companies are opting to negotiate directly with health care providers to apply value-based payment systems.

According to its survey, in 2017 only 6% of employers were pursuing the aforementioned plans. Twenty-two percent of employers surveyed said they intended to start working directly with providers to change the payment system in 2019.

More promising numbers from the same survey point towards a majority 65% of companies also making this a priority over the next three years.

This rising trend has put forth a lot of new exciting initiatives. On the ground floor, better care is already being seen. One such example is from something called a patient-centered medical home, where a team of medical professionals build a personal relationship with their patient to anticipate their needs and make sure they're cared for in the best manner. This would include screenings based on the patient's age, gender and medical condition.

This approach would be most likely used for patients with high-cost chronic conditions. David Lansky, CEO of the Pacific Business Group on Health, initiated something like this in his company's Intensive Outpatient Care Program.

Lansky explained that his organization:

"...identified 15,000 people with multiple chronic conditions and severe challenges in getting good care, and helped pay for primary care teams that would deliver coordinated care, address social needs, and address mental health needs, all under a prospective payment to the care team."

More and more companies are embracing this new value-based approach. The results are reduced hospitalizations and costs. Walmart's Center of Excellence program has also been leading the charge to cut costs and improve care with an integration of the best care it can provide for its employees.

While this is just the beginning in this new trend, we're already seeing that value-based payment models are incentivizing better care for all.

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How to do archaeology with place names

Mapping the frequency of common toponyms opens window on Britain's 'deep history'

Image: Helen McKenzie, reproduced with kind permission
Strange Maps
  • A place name is more than a name – it's a historical record of the name-givers.
  • By examining some of the most common toponyms, Britain's 'deep history' is revealed.
  • See where Danes, Welsh and Anglo-Saxons stamped their name on the land.

Trans-generational communication

This is Washington Old Hall, the ancestral home of George Washington, in the northern English town of Washington.

Washington DC is a place named after a person who was named after a place. This is Washington Old Hall, the ancestral home of George Washington, in the northern English town of Washington.

Image: public domain

Giving a location a name is a possessive act. It transforms an 'anywhere', a random space, into a 'somewhere', a certain place. A place with meaning, not just for the name-givers, also for later generations. Because place names are sticky. They can survive for hundreds, sometimes thousands of years. And even if today's toponym, worn with use, sounds different and lost its original meaning, it still remains a 'vector of trans-generational communication'.

In isolation, each toponym is like an archaeological dig – hiding multiple layers beneath a well-trodden exterior. In context, surprising toponymical patterns emerge. As in these maps by Helen McKenzie. She's disassembled British place names to examine the frequency of some of their most common constituents. They reveal deep history hiding in plain sight, on countless road signs across the UK.

Denmark's footprint in England

The toponymic \u200bsuffix -by is most prevalent in the area around the Humber.

The toponymic suffix -by is most prevalent in the area around the Humber.

Image: Helen McKenzie, reproduced with kind permission

Take -by (or -bie). It's one of the most common suffixes in place names throughout England, but also Scotland and Wales. Familiar examples include Grimsby and Whitby, on the North Sea coast; Derby inland, Formby on the Irish Sea coast and Lockerbie in Scotland.

There are hundreds of other examples, and they are among the most lasting relics of Scandinavian influence in Britain. By in Old Norse signified a farmstead or village. In modern Scandinavian languages, a 'by' still means village or city. In English, the word has also given rise to the terms 'by-election' and 'by-laws' – although pronounced differently than the suffix.

As the map shows, the suffix is most prevalent in the area around the Humber, and northern England in general. This is the core of what was once known as the Danelaw, a large swathe of northern and eastern England that was under Danish rule for about 80 years, until the expulsion of Eric Bloodaxe from Northumbria in the year 954.

But 'by' also occurs in Wales, as far south as Cornwall and as high north as central Scotland – testament to the scale of Scandinavian involvement in Britain.

The valleys of Wales, and beyond

\u200bThe green, green valleys of south Wales.

The green, green valleys of south Wales.

Image: Helen McKenzie, reproduced with kind permission

The anglicised version is 'coombe', which gives an indication of how to pronounce what looks like three consonants in a row. As the Welsh word for 'valley', it stands to reason that this toponym is most prevalent in the valley-rich south of Wales. Examples include Cwmbran, Cwmafan and Cwmfelinfach.

As for the comparative antiquity of British languages, Welsh is the much older rival of English. The post-Roman, pre-English inhabitants of Britain spoke a Celtic antecedent of Welsh. They were pushed west by the invading Anglo-Saxons. A telling – but disputed – piece of toponymic evidence is the Welsh word for England, Lloegr, which some say means 'lost lands'.

Better evidence are the many Celtic-influenced place names throughout England, including such well-known toponyms as Dover or Manchester. Focusing on Cwm and its anglicised variant, we find pockets throughout southern, central and northern England, as well as in Scotland.

Tons of -tuns all over Britain

\u200bThe area of central England around Merseyside has the heaviest concentration of -tons and -tuns.

The area of central England around Merseyside has the heaviest concentration of -tons and -tuns in Britain.

Image: Helen McKenzie, reproduced with kind permission

'Tun' is an old English word for enclosure that is cognate with Dutch 'tuin' ('garden') and German 'Zaun' ('fence') – for more on that, see #615 – and by way of 'ton' gave rise to 'town'. Perhaps the world's most famous example is Washington: the US capital's name derives from the country's first president, whose name comes from the eponymous town in northern England. Its name, in turn, probably originated as Hwæsingatūn, the estate (tūn) of the descendants (inga) of Hwæsa – an old English first name that means "wheat sheaf".

The Anglo-Saxons planted countless tuns/tons throughout England, with the second-highest concentration in the northeast, around Washington. The highest concentration, though, is centered on the part of central England towards Merseyside (Liverpool and environs), with Bolton, Everton, Preston and Warrington some of the best known examples.

But really, there are tuns and tons all over Britain, with distant areas of Scotland and Wales the only exceptions. Note the concentration in southwest Wales: southern Pembrokeshire, once known as Little-England-beyond-Wales.

Maps reproduced with kind permission of Helen McKenzie. For a few more maps on toponymy and a lot more on other subjects (including emploment density in Hackney and otter sightings in the UK), check out Ms McKenzie's Instagram, at helen.makes.maps.

Strange Maps #1037

Got a strange map? Let me know at strangemaps@gmail.com.

Predicting PTSD symptoms becomes possible with a new test

An algorithm may allow doctors to assess PTSD candidates for early intervention after traumatic ER visits.

Image source: camillo jimenez/Unsplash
Technology & Innovation
  • 10-15% of people visiting emergency rooms eventually develop symptoms of long-lasting PTSD.
  • Early treatment is available but there's been no way to tell who needs it.
  • Using clinical data already being collected, machine learning can identify who's at risk.

The psychological scars a traumatic experience can leave behind may have a more profound effect on a person than the original traumatic experience. Long after an acute emergency is resolved, victims of post-traumatic stress disorder (PTSD) continue to suffer its consequences.

In the U.S. some 30 million patients are annually treated in emergency departments (EDs) for a range of traumatic injuries. Add to that urgent admissions to the ED with the onset of COVID-19 symptoms. Health experts predict that some 10 percent to 15 percent of these people will develop long-lasting PTSD within a year of the initial incident. While there are interventions that can help individuals avoid PTSD, there's been no reliable way to identify those most likely to need it.

That may now have changed. A multi-disciplinary team of researchers has developed a method for predicting who is most likely to develop PTSD after a traumatic emergency-room experience. Their study is published in the journal Nature Medicine.

70 data points and machine learning

nurse wrapping patient's arm

Image source: Creators Collective/Unsplash

Study lead author Katharina Schultebraucks of Columbia University's Department Vagelos College of Physicians and Surgeons says:

"For many trauma patients, the ED visit is often their sole contact with the health care system. The time immediately after a traumatic injury is a critical window for identifying people at risk for PTSD and arranging appropriate follow-up treatment. The earlier we can treat those at risk, the better the likely outcomes."

The new PTSD test uses machine learning and 70 clinical data points plus a clinical stress-level assessment to develop a PTSD score for an individual that identifies their risk of acquiring the condition.

Among the 70 data points are stress hormone levels, inflammatory signals, high blood pressure, and an anxiety-level assessment. Says Schultebraucks, "We selected measures that are routinely collected in the ED and logged in the electronic medical record, plus answers to a few short questions about the psychological stress response. The idea was to create a tool that would be universally available and would add little burden to ED personnel."

Researchers used data from adult trauma survivors in Atlanta, Georgia (377 individuals) and New York City (221 individuals) to test their system.

Of this cohort, 90 percent of those predicted to be at high risk developed long-lasting PTSD symptoms within a year of the initial traumatic event — just 5 percent of people who never developed PTSD symptoms had been erroneously identified as being at risk.

On the other side of the coin, 29 percent of individuals were 'false negatives," tagged by the algorithm as not being at risk of PTSD, but then developing symptoms.

Going forward

person leaning their head on another's shoulder

Image source: Külli Kittus/Unsplash

Schultebraucks looks forward to more testing as the researchers continue to refine their algorithm and to instill confidence in the approach among ED clinicians: "Because previous models for predicting PTSD risk have not been validated in independent samples like our model, they haven't been adopted in clinical practice." She expects that, "Testing and validation of our model in larger samples will be necessary for the algorithm to be ready-to-use in the general population."

"Currently only 7% of level-1 trauma centers routinely screen for PTSD," notes Schultebraucks. "We hope that the algorithm will provide ED clinicians with a rapid, automatic readout that they could use for discharge planning and the prevention of PTSD." She envisions the algorithm being implemented in the future as a feature of electronic medical records.

The researchers also plan to test their algorithm at predicting PTSD in people whose traumatic experiences come in the form of health events such as heart attacks and strokes, as opposed to visits to the emergency department.

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