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Learning Objectives

  • Understand the basic definitions of value-based care

  • Explain the key elements of value-based care models

  • Discuss the value-based care issues particular to older adults

  • Identify different value-based care and alternative payment models

Key Clinical Points

  1. There are substantial efforts in process to shift toward value-based care models and these types of arrangements are likely to become more common in the future.

  2. Several alternative payment models are relevant to care for older adults. Examples include the Medicare Advantage (MA) program, accountable care organizations (ACOs), Programs of All-Inclusive for the Elderly (PACE), Institutional Special Needs Plans (ISNPs), the Merit-Based Incentive Payment System, and the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP).

  3. There is no silver bullet in achieving value-based care. Rather, each initiative has strengths and drawbacks and forms a part of the greater whole.

The purpose of this chapter is to provide an overview of value-based care as it currently exists in the United States, and to highlight aspects of common value-based care models that are most relevant to the care of older adults. In many respects, geriatricians and other geriatric health professionals are in a position to make these value-based care models successful and to assume leadership roles in them. Value-based care requires health professionals to work as interprofessional teams and participate in care coordination across settings of care, to understand evidence-based care and as well as its limitations in older adults, and to practice person-centered care in the context of evidence and many other factors important to patients—all skills that geriatricians and other geriatric health professionals have developed.

At the same time, older adults with multiple comorbidities and related health care needs are likely to benefit from being in one or more value-based care models when implemented effectively. These individuals are especially susceptible to the potential for excess diagnostic testing, therapeutic intervention, and related complications and costs that are common in the Medicare fee-for-service system. Value-based care mitigates the incentives that create this situation and can therefore result in better outcomes and lower costs for the vulnerable older population.


In most industries, value can be defined as the output achieved relative to the cost incurred. In health care, the most common definition of value is the patient health outcomes achieved per dollar spent. Central to the concept is that the value should be to the patient. Importantly, value is defined by both the quality of outcomes and the costs incurred. Cost-containment efforts without a focus on improving value may negatively impact patient health outcomes. Efforts devoted to improving quality metrics alone may not be sustainable or may not meet the needs or preferences of patients.

In the Porter model of value-based care, the outcomes that a patient experiences can be considered the numerator, while the cost of providing those outcomes can be considered ...

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