Necessities for the Assessment and Delivery of Value-Based Critical Care: Empirical Evidence and Systemic Considerations*

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The Affordable Care Act was signed into law in March 2010 and provided a number of tenets to improve the access, quality, and cost of healthcare (1). One of those tenets, the establishment of Accountable Care Organizations (ACOs) (2) advanced two major concepts: population health- and value-based care. In an ACO, a population of patients is assigned to a primary care provider who is then responsible for the overall quality and total costs of care for that attributed population. Achieving higher quality at a given cost, thus, improves the value proposition of the healthcare services received for the commodity under consideration.
Though a bulk of literature has investigated quality, efficiency, and value conversations for ICU patients (3–5), little research has explored advancing the “health” of those patients using population health management strategies. Barriers to this line of research may begin with the fact that ICU care is generally encounter based, and, as a result, readmissions are less common than compared with non-ICU care. In addition, perhaps as ICU professionals, we have not appropriately focused on the “upstream” prevention aspects of our services. Finally, there are a host of other specialists and professionals who take responsibility for patient care after ICU discharge and through rehabilitation and potential convalescence. Nonetheless, critical care practitioners have demonstrated an ability to adapt over time when presented with empirical evidence that demonstrates improved outcomes for the patients and families we serve.
Perhaps this issue of Critical Care Medicine provides one such example where we will wake up in 20 years with a new approach to delivering ICU care, only to have it start with the conceptual framework presented by Leung et al (6). Specifically, Leung et al (6) introduce a framework and corresponding “roadmap” for advancing the work of Critical Care Organizations (CCOs) in support of value-based care delivery for populations of critically ill patients. The proposed framework involves two phases: horizontal and vertical integrations. Horizontal integration requires the reorganization of the health system ICUs such that they collectively operate under one umbrella whereas, vertical integration involves the interaction of several provider platforms such that the healthcare of ICU survivors can be managed across acute and postacute care continuums (6). Although this approach may ultimately be considered innovative in nature, there are several limitations to the model “today” that should be addressed prior to any discussion one may consider with health system administrators.
First, the model lacks empirical evidence for demonstrating a difference in populations of critically ill patients cared for under a CCO. A basic science or clinical article that presented a hypothesis using an argument based on collective opinion without 1) statistical reference, 2) a rigorous methodologic approach, or 3) data-informed outcomes would be dismissed out of hand (7). Without an investigation of impact on structure, process, and outcome, one can never know whether a new model will actually improve or negatively impact the care we provide. Only one study, which was a descriptive report of CCO governance models (8), was mentioned during the justification of horizontal integration. Thus, evidence to support this operational alignment and resulting value-based care improvements, based upon the proposed CCO model, is anecdotal until proven otherwise.
Second, the overview of vertical integration mentions the coordination of ICU care delivery with “alliances” such as hospital medicine, palliative care, inpatient rehab, and nutrition; yet, there is no description of what this entails operationally for each participating discipline. When reorganizing or developing operational structures, roles, or programs in a given health system, it is critical that we consider the systemic impact that each discipline has via its cascading involvement.

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