The Push For Value-Based Care

by Rose Rohloff
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But, what is value? Is society conditioned to accept low quality as value, because a lower standard has become the norm?  

Value is a relative term based upon personal perception, and oftentimes great marketing. True value is based upon insightful knowledge of what entails quality along with the cost of delivering goods and services. Value-based care is the new buzz for basing reimbursement in the healthcare industry. But again, what is value care: personal perception, marketing, cost?

This article was conceived after several conversations regarding what defines quality care, with veteran clinicians (nurses and doctors), insurance brokers, as well as numerous 40-80 year olds who make up the typical population across the country. Using the following encounter as an example, I want to review what determines true value of care delivery compared to the normal perception being marketed.

A surgeon office within a surgical center, (the surgeon with privileges at two leading health systems), has 5-star Healthgrades ratings, including comments: the staff is courteous; appointments start on time; the Physician Assistant (PA) is very intelligent, knowledgeable, articulate and caring; and the surgeon with a benchmark performance staff. There are also one star ratings including a comment the staff is not properly trained and do not know how to maintain a sterile environment.

The primary issue with such score deviations is determining if poor marks are isolated instances (one offs); or, if the variance of only highest and lowest reflect the knowledge of reviewers. Are the high ratings from non-healthcare persons based on perception of the veneer friendliness and scheduling, with one star comments based on specific quality requirements, care competency posted by those with healthcare insight/experience?

As a 35+ year healthcare veteran, an answer was determined accompanying a Medicare patient ‘John’, in his mid-80s who experiences early stage dementia, to the office for a post-op visit for a leg stint placement.

Upon arriving, another elderly patient (80s) was sitting outside, unattended in wheelchair, hot sun, 100 degree weather, no water. When asked why he was there, he stated, “I can’t stand the freezing air conditioning inside while waiting for a ride.” After walking John into the lobby, the gentlemen clearly seen through the glass door was pointed out to the receptionist stating that he was left in hot sun, no water, unattended. The receptionist stated, “It is his choice to stay out there.” I then stated, “Get someone to check on him, give him water, put him in the shade and check when his ride is supposed to arrive and monitor him if it is delayed or bring him inside.”

One person escorted us back to exam room. She did not introduce herself or her title. She proceeded to take the blood pressure with no other vital signs (unknown if a secretary, an aide, a nurse or tech).

She then asked the patient, “How much do you weigh?” He gave a number. As patient champion I responded, “He doesn’t know, he has not weighed himself. You need to weigh him yourself.” She responded, “We don’t have a scale.” She then left. I followed her witnessing her  documenting the incorrect data.

I reiterated he has dementia with no idea how much he weighs. She replied, “It doesn’t matter anyways, we just need to put something in the record.” She was reflecting an 11 pound weight loss from previous recording. It is unclear if they performed the previous weighing, if it was done just prior to surgery to determine proper anesthesia delivery for his surgery.

Another woman in scrubs entered the exam room without introducing herself or her title, asking John to remove his shoes and socks. (The scheduled appointment was with the PA so the patient assumed her identity.)

She asked him if his wound was healed and he replied, “Yes.” She documented something in the chart without ever assessing his wound for healing or determining if there was infection.

She bent down and felt his feet with her whole hands stating they feel warm, and then asked if he had numbness in his feet. John responded, “Yes.”

Having worked as a registered nurse (RN) in cardiovascular and neuro intensive care units (ICUs), I know she never did pedal (foot) pulse checks x4 comparing both feet. She never assessed location of numbness, or if chronic/intermittent, positional with sitting/, standing, walking, etc.

The family had asked if aspirin could be stopped as the patient has experienced nose bleeds in the past. The staff person responded yes and since there was 90% blockage of the previous stint, it was cleaned out and continue Plavix. There was no establishment of lab work as part of care plan determining effectiveness of the medications, especially since the previous stint occluded.

"1,750 or so stent patients are also prescribed Plavix to prevent clots from forming around the stent, but of that group, approximately 500 (29%) carry a genetic variation that prevents them from converting Plavix into its active form. This gene-related lack of response stands to be "especially severe" in about 50 (3%) of those patients, who won't derive any benefit from Plavix - 2010 Vanderbilt Medical Center

She then stated they would be ordering an ultrasound as a standard post-op test to determine the effectiveness of the stint - over three weeks after the procedure.

Why didn't they do the ultrasound during the post-op visit to have results to make sure the stint was effective? ​No doppler was used to assess extremity blood flow.

She stood up, touched the paperwork, the marker and laminate sheet then touched the door handle leaving – never having washed her hands before assessing the patient, nor after putting her hands on his feet.

Perceived value based on quality versus true value and cost

The office visit was charged to Medicare, with an elderly patient perceiving the staff as nice during the office visit.
The care competency and quality as true value-based care during the visit includes:
   - lack of basic cleanliness standards with severe cross contamination practices
   - no introduction of name or title of any staff member
   - fraudulent documentation in the electronic medical record (EMR) 
   - no assessment performed during a specific post operative visit (a family member could have taken the BP and said his feet felt warm.)
   - lack of care planning and evaluation of medication regime
   - unnecessary secondary office visit charging for follow up
   - another elderly patient left unattended in the hot sun
If the U.S. healthcare system wants to achieve true value-based care, we need an educated population, higher accountability of staff standards with the ability to send evaluations direct to payers based on specific facts and not emotion, and surveys must include care competency reviews versus only veneer questions of politeness, room appearances, and on time scheduling.