I tend to see both terms in research articles: value-based health care and cost-effective analysis. Typically the cost-effective analysis articles also reference quality-adjusted life year (QALY). Both terms tend to have quite a bit of mathematics involved in determining either value or cost-effectiveness.

It seems value-based health care is more focused on the patient – capturing not only outcomes, but also the patient’s experience and the the patient’s perspective about the services provided. Obviously mathematics is involved – typically more in the area of determining payment for services. 

Cost-effective analysis often times feels “cold” to me. It focuses on the numbers. There is a cut off dollar amount that indicates the “value” to the intervention. From the studies that I have looked at, it doesn’t seem to pull in outcomes data. It uses a utopia figure of one year of perfect health. So it looks at alive versus dead and the quality of life if alive. The quality of life aspect just seems arbitrary and maybe even kind of imaginary to me. From my perspective, cost-effective analysis seems more complex to understand and is less concrete than value-based health care. 

I pulled this abstract to share because we may begin to see a merging of sorts between the two terms as various quality payment models are proposed.

You’ll find the abstract to the recent study below.

Value-Based Health Care Meets Cost-Effectiveness Analysis.

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The FOTO Team recently released the availability of a Net Promoter Score (NPS) Dashboard.  The NPS consists of one simple question, “How likely are you to recommend us to a friend or colleague?” The FOTO Team included the NPS Dashboard as a bonus twist turning it into a management tool. Your patients will be able to add comments after responding to the question and receive real-time alerts of detractors. 

There are quite a few articles online focused on scoring and the interpretation of scores. If a patient indicates 0-6, then that patient is considered a detractor. If a patient responds 7-8, then that patient is considered a passive. Finally if a patient responds 9-10, then that patient is considered a promoter. The score is actually calculated by the percent of promoters minus the percent of detractors multiplied by 100.  I’m choosing not to spend a lot of time on the scoring because most of what you find online goes into substantial detail. What I’d like to do is instead take time to provide you with hurdles and strategies that you will need to think about so you may be effective if you choose to use NPS.

The biggest hurdle for your organization is to determine what to do with NPS scores. Should the scores be something you track? Should the scores be something  you share with everyone in your organization? Should the scores have an action plan? Do the scores really matter?

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Is my Net Promoter Score acceptable?

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Will your organization have a targeted goal for your NPS results? I’ve been researching NPS and what you may find helpful is benchmark data from CustomerGauge. Their 2018 benchmark report may provide you insight as to what would be considered a reasonable result when capturing NPS. Within the benchmarked data, the industry actually matters with regard to Net Promoter Scores. As you can see, healthcare and professional services tend to have higher scores. If you decide to implement NPS into your business model, you might want to set a score goal. The score represents the accumulation of touch points within your organization for every person who interacts with patients. This score is not specific to clinicians; this score captures the patient’s perception of the whole experience from the first contact with your organization (either website, email, phone or walking in) to that last day of graduation.

Your next hurdle has to do with an action plan for detractors. If you choose to have the NPS within each patient functional status report, anyone within your organization will be able to easily identify if the patient is a detractor. Then what? What action plan will your organization implement? Should a detractor be addressed? Who should address detractors? As you think about this, keep in mind that organizations that have an action plan in place reaching out to detractors seem to demonstrate improved revenue. Revenue may improve because the detractor might flip to a promoter: choosing services in the future and referring others. I’m assuming this happens if the customer truly believed the organization cared and really worked toward addressing the detractor’s needs.

Should a promoter be seen as a hurdle in your organization’s strategy? Okay, a promoter probably isn’t a hurdle, yet you do need to think about promoters. Can you harness your promoter’s exuberance toward your organization and help make it easy for increased referrals? To me, referral marketing feels like it cheapens the kindness extended by the promoter. Although there may be some in this world who expect something for doing something, there are many others who truly appreciate helping others just because. I tend to send a quick thank you note to previous patients who refer others. To me, that just seems special – to receive something handwritten in the mail with a heartfelt thank you.

Speaking of which… do you track how your patients choose your organization? To me, the NPS is just one piece of the equation. The other piece of the equation are behaviors. What I mean is that anyone can say that they would refer… but who actually takes action and does refer? If you add that bit of information into your organization, you have both the NPS and behavioral information. If you believe that it costs less to retain your patients and make them lifelong customers, then it would probably be wise to know if you really are retaining them. It’s important to know when scheduling an initial evaluation if the patient is a previous patient, referred by a previous patient, specifically referred by another healthcare professional or choosing based on location or marketing efforts. 

One last thought about what the FOTO Team has rolled out that is different. The FOTO Team has provided an option for patients to comment after responding to NPS. By providing the opportunity for a patient to comment allows for two things. If the patient is a detractor, the patient may actually share what is bothersome. Your organization will have concrete information from that patient and a more efficient process to address the negative comment. For the promoters who share a comment, you now have an opportunity to use the comment as a testimonial. Depending on the comment, you may even have a way to reach out to that patient expressing gratitude.

The NPS is just a score. The score should drive action to help you improve the interactions your organization has with patients. Although NPS seems to be a loyalty gauge, the real power, growth and advantage is truly based on what your organization does with the score. FOTO now provides an NPS dashboard as a customer experience management tool. 

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Until next time,

~Selena

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More and more studies indicate the value of guidelines to improve clinical practice, reduce cost and improve outcomes. It would seem that guidelines should make an impact on practice.

In this particular case, I forgot about common sense. 

Before implementing  guidelines within an organization, it is probably wise to first know current practice patterns. Even better than that, it might was wise to actually know your organization’s outcomes. If your clinicians are already knocking their performance out of the park and providing fantastic service with outstanding outcomes, it’s probably a waste of time. From a psychological perspective it probably feels clinically demeaning to your stellar clinicians. 

There is definite value in guidelines – the actual act of implementing guidelines is fully dependent upon how a clinician is currently practicing.

You’ll find the abstract to the recent study below.

Does a tailored guideline implementation strategy have an impact on clinical physiotherapy practice? A nonrandomized controlled study.

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Saving employers $18 million is definitely something of which to be proud. I have no idea if the savings has been since the origination of the program or for 2017. My brain immediately began pondering “value-based care.” The definition I associate with the term includes quality and cost. At the same time, in my mind, the patient is at front and center because the program should make a positive impact on the patient’s life.

 Through some of the details in the news release, I glimpsed a little bit of how the Spine and Joint Solution provided some level of quality of care.  The program reduced readmission rates by 22% and complication rate by 17% for joint replacement surgeries. For spinal surgeries the readmission rates were reduced by 10% and the complication rate reduced by 3.4%.  I tend to think that for patients undergoing joint replacement surgery that these outcome changes seemed meaningful. For the spinal surgeries, the changes seem minimal. In reporting readmit and complication rates, I think I would more appreciate knowing number of total surgeries and number of readmits and number of complications. When it comes to readmits and complications, what is the baseline normal expected rate? I mean, zero is unrealistic. What is the expected norm for these rates? 

What I didn’t see shared were actual outcomes of how the patient was functioning after the surgical procedure. I mean, we all know that “failed back” surgeries are a thing. We also know that there are patients who are not able to walk up and down stairs normally after a hip or knee joint replacement. Readmission rate and complication rate are the initial quality measures. At some point, the value based care programs need to consider the quality provided outside of the initial 90 days of care.  What are outcomes at 6 months and 12 months after the procedures? Granted, in doing so, the payer would have the burden of assessing the real outcomes.

Within the news release,  this particular detail affected my thoughts.

Eligible employees saved more than $3,000 in out-of-pocket costs per procedure when accessing a participating facility rather than another in-network medical facility, with incentives such as cash, gift cards, additional vacation days for recovery, and health savings account (HSA) contributions.

The Spine and Joint Solution is a bundled payment program. The employer and payer risk is substantially reduced when the cost is a fixed cost. A known procedural cost that has obviously been set to reap savings for the employer and the payer allowed additional monies to be allocated to employees for incentive purposes. We really don’t know the associated cost for the employers because incentives were also being provided. UnitedHealthcare would have no control or ability to account for this aspect of how the program was implemented by an employer. The reported savings are elevated due to the inability to take into consideration the employer financial incentives.

Although there isn’t an easy solution for alternative payment models, I’d like to think there are three key components that could be negotiated in new contracts when rehabilitation services are included in the care provided to patients.

1. Payment not only based on the short term procedure focused on the first 90 days, but also payment inclusive of downstream savings.
2. Payment based on long term outcomes that are meaningful to patients. 
3. Payer has “skin in the game” and includes benefit policies that reward the desired behaviors with substantially reduced deductibles, coinsurance or copays when the care pathway a patient chooses favors the high quality option.

As a bonus, I also think that the payer should also be providing reports to providers. In order for health care to be better, the payers also need to be held accountable with regard to their role, which should be expanded to include more than just monitoring providers, paying bills and focusing on reducing their payments. The payers should be able to provide providers with risk adjusted data about the patients the providers treat, along with how touchpoints with providers affect change in the patient: medication use, health factors, preventative care, and hospitalizations. Payers have more data then imaginable and the time has come that payers need to remove themselves from their silo and begin to create dashboards of information to provide big picture information to providers.

Until next time,

~Selena

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