What Does Value, Value? Discipline, Compliance, and Profit in Value-Based Payment Reform

Background and Purpose:

Value-based Care (VBC) represents the latest “policy fad” (Marmor 2007) that claims to provide a panacea for the woes in the US healthcare system, conceptualizing and simplifying value as a function of Quality divided by Cost. However, the flattening of healthcare delivery into such a disarmingly simple formula effectively “erases” the political, economic and ideological interests of a specifically formulated network of elite actors including private equity investment firms, for-profit payer groups like United, and large, vertically integrated provider networks.

Very little research has explored the impact of these aligned networks of actors, and none has explored their overlap with Value-based Payment reforms and VBC’s key regulatory lever, the Center for Medicare and Medicaid Innovation (CMMI). This paper will help to open-up this area of research to further analysis by identifying the key thematic components of VBC as envisioned by these networks of actors, and the implications this envisioning has for provider groups like Social Workers who become refigured not primarily as providers, but as cost-containment mechanisms and actuaries responsible for managing patient’s (financially) risky health behaviors.

Methods:

This study focuses on qualitative data collected from 5 leading interdisciplinary conferences organized around value-based payment reforms. Conferences were chosen as a site where difficult-to-access stakeholder groups intersect to form coalitions, share information, coordinate activity in the sector, and engage in brief periods of visibility. Sessions were recorded, transcribed and analyzed using critical discourse analysis (CDA) (Jessop 2004, Fairclough 2003 and Sum 2009). Organizational mappings were utilized to identify overlaps and coordination between elite actor groups and regulatory activity within the CMMI.

Findings:

Themes were identified involving cost-cutting, risk-shifting, and disciplinary techniques (Foucault 1975, Park 2020) towards both patients and providers, as well as centering mental/behavioral health providers as a key “node” of cost savings for investors and large, vertically-integrated provider systems. Discourses around quality are backgrounded, with no explicit logics justifying the improvements of outcomes because of cost-cutting. Organizational mapping indicated coherence and coordination between private equity firms, large for-profit payers such as United Healthcare and Aetna, vertically-integrated provider groups, large hospital conglomerates, Medicare Advantage plans, free-market conservative think tanks such as Mercatus and Duke Magnolla, and federal regulators within the CMS and CMMI, despite repeated failures of VBC pilot programs to deliver on either cost-savings or quality improvements.

Conclusion:

Value-based Care represents a “policy fad” which seeks to legitimate itself through an appeal to existing technocratic discourses around containing healthcare costs and balancing budgets. However, in so doing and utilizing the organizational networks leading proponents have formed, Value-based Care seeks the privatization of publicly-funded programs such as Medicare and Medicaid, attempts to protect the controlling role played by large payer groups in determining healthcare, and shifts the role of providers towards care-rationing and disciplining of patients. What does Value, Value? Through its discursive framing and the activities of its leading proponents, this project suggests it values privatization, profits, consolidation and the reconstruction of provider-patient dynamics in service of these goals.