At last year’s HIMSS22 in Orlando, Florida, the Digital Medicine Association (DiMe) and the Veterans Health Administration (VHA) value-driven framework To evaluate innovation in healthcare.in a recent interview with healthcare innovationCole Zanetti, DO, MPH, Acting Director of Value-Based Care at the VHA’s Center for Care and Payment Innovation (CCPI) and Senior Advisor to the VHA Innovation Ecosystem, believes that the framework We discussed how it is applied in
HCI: First, what is the mission of the Center for Care and Payment Innovation?
Zanetti: Its focus is to test and pilot new care and payment innovation models within the VA, the largest integrated healthcare system in the United States and dramatically different from the private sector. One of the basic tools at the Center’s disposal to facilitate this is waiver powers. This would allow the VA to pilot new care and payment innovations by asking Congress to waive certain laws governing hospitals, nursing homes, housing, and health care. increase. You can also request an exemption from any policy within your VA to allow you to test new opportunities that may be restricted by current policies or mandates.
As an example, if there is a veteran suffering from rheumatism problems in a rural area, and there are not many rheumatologists in the area, the Veterans Administration will ensure that a doctor working for the Veterans Administration provides this veteran with the following: care can be made available. anywhere in the country. Due to the way workloads are captured and how funds are distributed within VA, it’s actually not happening as often as you might think. The CCPI is beginning to look at the data to better understand this kind of opportunity for resource sharing and identify ways to help rebuild the system and continue to move VA to a value-based healthcare system. .
Elsewhere in the health care system, when people use the term value-based care, they are usually referring to a population health approach and capitation, rather than fees for services. How does that definition fit into what’s happening at VA?
Zanetti: VA fortunately does not have the same restrictions as the private sector. For example, there are programs in which community he workers provide outreach to help veterans struggling with suicidal thoughts. There is no ICD-10 code associated with that kind of activity, but it’s the right thing to do and we do it anyway. Unlike the private healthcare system, we are funded directly by the government. That means we can look across the system to identify where funds can be distributed to have the most meaningful impact on health. This is how we invest in value-based programs like those that help veterans struggling with suicidal thoughts.
Also consider what is under the control of the medical team. Let me give you the most classic example. I am a family doctor. You may receive notification that a patient’s diabetes blood test, HA1C, has not been completed, but the records show that you have ordered lab work for that patient. We also contacted the patient to schedule lab work, but the patient did not show up for the appointment. So get social her workers involved and find out how best to support them. We are doing everything we can to help our patients, but we are still “failed” because they didn’t finish that lab. Using a value-based approach to care can measure all the evidence-based work that care teams do to care for their patients. At the same time, it can also help understand and account for factors beyond the control of the medical team. Requires medical teams to do what is necessary and practical because they need to ensure that the outcome or process measurements assigned to teams or individuals are evidence-based and under their control .
Is it part of the center’s work to tune them better, look at the VA to see which kinds offer the most value, and scale them up across the system?
Zanetti: absolutely. Let me give you a good example of how we do this. VA has been working with what it calls a remote temperature monitoring system that uses remote technology to tell people with diabetes if they are at risk of developing diabetic foot ulcers. We have used this in multiple VA settings and it has helped reduce veteran amputations. Ultimately, this means that veterans will come to the doctor less often and have fewer complex health problems because the system works so well. , the per-service funding system does not consider the resources required to maintain this program, nor the fact that it has actually improved the health of veterans, and thus many people participate in this program because they have less patient encounters. It is possible that less funding will actually be required by the facility that is doing so. , that is our goal.
Our work at CCPI is to point out the gap between what we know to be true about health outcomes and what we are measuring and funding. In this example, we work to reconcile that inconsistency using time-driven activity-based costing, looking at health outcomes to determine what we need for scalability. We will also examine how the system impacts health equity and access for veterans who can leverage this technology. We will then make recommendations to the VA and possibly Congress on how to change the system to allow this value-based care solution to grow. Whether it’s a remote temperature monitoring system or another model of care delivery, the CCPI is constantly asking whether there are meaningful improvements in health conditions that are difficult to scale over time due to the impact of the system. We are working to remove these obstacles, test and iterate to define a new system that encourages these behaviors, and how to scale it across the country.
And is it relevant to the work your team is doing? Digital Medicine Society What about a framework for identifying that kind of value?
Our organization is working with DiME to develop frameworks and principles to guide value-driven innovation that touches on access, effectiveness, efficiency, equity, meaning, relevance of scale, and time to value. I have been working to establish. This is an important tool to help CCPI and VA measure the value and impact of new healthcare innovations. Within that framework, we’ve defined each category in more data-driven detail, so you can be sure you’re using a consistent lens when evaluating opportunities to test or scale your project.
Can other large healthcare systems use the same kind of framework to measure the value of innovation, or are there more restrictions on how things are paid for?
Zanetti: If you look at the major healthcare systems, most healthcare systems have a mix of payers.There are some contracts at risk, per-service pricing agreements, global payment agreements, and more. In some cases, there may even be several different payers within a single market. And it’s always changing. Most of these various entities also have their own quality indicators that differ from each other. My mind was blown when I first learned that there are 4 different ways he can measure high blood pressure as a quality marker!This is an obvious struggle that the private sector continues to have.
Part of the reason I came to VA from the private sector, beyond being honored to have the privilege of caring for our country’s veterans, is what kind of care the Veterans Corps has. And I thought it could serve as a beacon of what payment models should be. CMS and the private sector. VA has great opportunities and flexibility to do this. That’s why VA was a leader in telemedicine long before the COVID pandemic. What we can demonstrate effectively can be part of the conversation about what changes should happen in the private sector. and achieve the cost avoidance necessary for long-term sustainability.
