The shift to value-based care in the United States has been slow in coming, in large part because providers have continued to cling to the traditional ‘fee-for-service’ model of health care that historically has worked well for them.
The shift to value-based care (VBC) in the United States has been slow in coming, in large part because providers have continued to cling to the traditional ‘fee-for-service’ (FFS) healthcare model. ) which historically has worked well for them (if not always for the patient). Plus, that’s how they’ve always done business.
But the inefficiencies and rigidity of the FFS have been exposed during the COVID-19 pandemic. Providers were suddenly faced with the shocking reality that in a fee-for-service model, no service means no fee. Revenue plummeted as patients canceled elective surgeries and clinicians’ offices restricted patient hours and volumes.
In contrast, value-based models of care reimburse providers who deliver better outcomes for patients and populations while reducing costs. The emphasis is on the quality of care, not the quantity.
Technologies that allow clinicians to tailor care plans to address each patient’s unique health risks are essential for successful BCV operation. Fortunately, huge advances are being made in genetic testing and precision medicine, which allow clinicians to use a patient’s genetic makeup and other molecular data in the delivery of care.
The BCV shows particular promise in helping providers treat patients with chronic illnesses. The Centers for Disease Control and Prevention (CDC) estimates that 90% of the country’s $ 3.8 trillion in health spending in 2019 was spent on treating people with chronic and mental illnesses.
It’s no wonder why: Recent research shows that 51.8% of adults in the United States have at least one chronic disease (such as heart disease, cancer, stroke, chronic obstructive pulmonary disease or diabetes), while 27.2% have two or more chronic conditions. Another study shows that more than half of the elderly in the United States have three or more chronic diseases.
And that’s when things get expensive. An analysis by Rand Corp. concludes that while Americans with five or more chronic diseases make up only 12% of the population, they account for 41% of total health care spending in the United States. .
As America’s population ages, the total number of people with chronic diseases – and the associated costs – will in turn increase. The PFCD predicts that the total cost of chronic disease (both in terms of medical spending and lost worker productivity) in the United States from 2016 to 2030 will reach $ 42 trillion. The PFCD also estimates that 1.1 million American lives could be saved each year through better prevention and treatment of chronic diseases, reducing health care spending by $ 418 billion each year through 2030.
However, better prevention and treatment can only be achieved through VBC payment models that reward quality care as well as the use of technologies such as precision medicine, advanced genetic testing and pharmacogenomics.
Through targeted genetic sequencing, clinicians can spot changes in an individual’s chromosomes, genes or proteins. With this information, clinicians can identify patients most at risk for developing chronic disease before the disease develops or progresses and requires more expensive long-term care. Additionally, early genetic testing may motivate at-risk patients to make lifestyle changes (such as quitting smoking or exercising more) or to take prescribed medications to control their chronic illnesses.
Let’s say that next-generation targeted sequencing (NGS) test panels from a clinical lab show that a patient is at risk for hypertension. Clinicians can use this information to work with the patient on lifestyle changes and strategies to control their blood pressure.
Additionally, providers may want to prescribe medication for this patient based on the NGS results. This is where pharmacogenomics is invaluable. Pharmacogenetic tests (PGx) can reveal genetic variations that affect a patient’s response to specific drugs. This information saves time and money, as clinicians do not have to experiment with different drugs.
Knowing precisely what medications to prescribe a patient also minimizes potential side effects of the medications. Reducing adverse drug reactions can reduce medication nonadherence, that is, when patients do not take medications prescribed by clinicians for chronic conditions, illnesses and other disorders, often for example. fear of harmful or debilitating side effects. “Medication nonadherence represents billions of dollars in preventable health care costs, millions of avoidable hospital days and thousands of avoidable emergency room visits,” writes the CDC.
In addition to enabling personalized treatment plans for individual patients based on their unique genetic makeup, precision medicine and genetic testing provide data for medical researchers to better understand chronic disease, which over time , will lead to improved prevention, diagnosis and treatment.
The American Medical Association (AMA) has advocated for several years that precision medicine and genetic testing are essential parts of value-based models of care. While barriers remain to the large-scale adoption of precision medicine and genetic testing, the benefits of these technologies – as well as of BCV models that emphasize prevention and holistic care – are growing. more and more undeniable. It will only be a matter of time before BCV, precision medicine and genetic testing enter mainstream healthcare.
Ron King is the CEO and Board Member of Tesis Biosciences. King is a seasoned healthcare executive with over 25 years of experience in the healthcare industry.