Understanding Value-Based Healthcare. Christopher Moriates, Vineet Arora, and Neel Shah, New York: McGraw Hill Education; 2015. Softcover, 402 pages, $49.50 on Amazon.

On April 16, 2016, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law. "MACRA makes sweeping changes to how Medicare pays for physician services. The law also requires the Centers for Medicare & Medicaid Serves (CMS) to implement, by 2019, a new two-track payment system-the Quality Payment Program (QPP)-for physicians and other eligible clinicians. How CMS implements the changes contained in the MACRA will have a significant impact, not only on physicians, but also on the hospitals and health systems with whom they partner."1

The rules committee for the MACRA is meeting as this column is being written. This bill fundamentally changes the reward system for providers from procedure-based payment to value-based remuneration. How will the rules committee define value and the related variables? How will both clinicians and nonclinician administrators interpret value and the impact on practice?

Advanced practice registered nurses (APRNs) are one type of provider affected by the MACRA. To understand and prepare for this monumental change, we must first understand value-based health care. This is not an easy task even though the concept of value in health care is not a new one. In fact, Porter and Teisberg addressed it in a book I reviewed for NAQ in 2006, Redefining Healthcare: Creating Value-Based Competition on Results. 2

A more recent take on the subject is Moriates, Arora, and Shah's Understanding Value-Based Healthcare. In this comprehensive book's forward, the significance of the author's work is described:

There are other resources focusing on the individual elements of value: cost, quality, access, patient safety, and patient experience. And there are books that explore many of the contextual determinants, such as the payment and regulatory systems. But, until now, there has not been a single book that brought together each of these domains in the service of helping clinicians and non-clinicians understand and improve healthcare value. (p ix, Foreword by Robert M. Wachter, MD)

What is meant by "value"? How do the authors define it in health care? Chapters 4 (Defining Value: Connecting Quality and Safety to Costs of Care), 10 (Barriers to Providing High-Value Care), and 15 (Shifting Incentives: Moving Reimbursement From Volume to Value) are devoted to defining value. Simply put, "value in healthcare is quality divided by costs, or, more specifically, health outcomes achieved per dollar spent. However, there are currently substantial challenges in appropriately defining and measuring these variables" (p 91). The complexities of value in health care are exactly why we need this book. Moriates, Arora, and Shah have organized their book into 3 parts:

1. Introduction to Value in Healthcare (6 chapters)

2. Causes of Waste (4 chapters)

3. Solutions and Tools (6 chapters)

Each chapter ends with a summary of key points in addition to an extensive reference list. What will particularly please clinicians of all disciplines are the Stories From the Frontlines, threaded throughout the book. These stories cover such realities as "sticker shock," which point to the frustration of doing everything clinically appropriate for the patient, who ends up with an expensive bill due to bureaucratic demands (such as not getting every clinician approved by the insurer, which forms were submitted).

Other stories from the frontline include:

* "Actually, Hi-Tech imaging can be high-value medicine" (pp 86-89);

* "Pricing Variation: the case of the $517 Chest X-Ray" (pp 136-137);

* "A diet of Limitless Technology" (pp 161-162);

* "The Hidden Cost of Lacking Primary Care" (pp 177-176);

* "I'll Do It for $1100" (pp 194-195); and

* "Teaching Value-Arizona" (pp 344-346).

This book is intended for those who are care providers. Although a good portion of the book is from the physician perspective, others (including nurse practitioners and APRNs) will benefit from reading it. The authors provide a foundation for analysis by care teams as they map out their own solutions to an evolving health system. They ask tough questions, such as, "Do we even know how to accurately measure quality or value?" (p 314) They also share strategies from across the country, such as, engaging patients in decision making, establishing Accountable Care Organizations, learning high-value medication prescribing, implementing value-based initiatives, and creating financial incentives. Because this book addresses so many of the complexities around today's health care, it makes a good 1-stop reference.

(Note: this book was written in association with Costs of Care, Inc, a 501C3 nonprofit formed in 2009, and directed by the authors of this book.)

-Elizabeth (Betty) Falter, BSN, MS, RN, NEA-BC

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