Unique among most Western countries, healthcare in the United States operates as a business. Hospitals, clinics, surgical centers, and other facilities have to attract patients by offering them high-quality care. Because patients usually have choices about which providers they see and facilities they visit, healthcare organizations must use advertising to attract customers. Otherwise, they lose money and must close their doors. So how does a healthcare organization balance profit and high quality, value-based care?
While the business of healthcare may make some people uncomfortable, the truth is that the two can coexist in harmony. There may actually be some benefits to this combination.
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Value-based care
The term value-based care describes a system that focuses on provider performance, patient experience, and quality of care. This phrase is often used by Medicare and Medicaid to encourage providers to focus on the quality of care over the quantity of patients seen, with an emphasis on providing holistic care to each patient.
For example, rather than simply sending a patient home with a rescue inhaler for an asthma exacerbation, the healthcare team helps them make a plan to quit smoking, reduce allergens in the home, start a maintenance inhaler, and discuss other lifestyle changes that will help to avoid a flare-up of symptoms.
Healthcare professionals also refer to value-based care as person-based care. The healthcare team should create a care plan that allows patients to make informed decisions and meet their own identified healthcare goals.
Financial impact of healthcare
Healthcare has financial implications for both individuals, businesses, and the nation as a whole. Research published by KFF shows that healthcare costs continue to rise at a rate much faster than inflation. Healthcare costs in the United States reached $4.5 trillion in 2022, with the average out-of-pocket spending per person reaching $1,425 per person per year.
While healthcare spending has increased exponentially over the last few decades, healthcare utilization has not. This indicates that high prices are to blame for the high cost of healthcare, not long hospital stays or increased numbers of patients. Unfortunately, high cost does not translate into higher quality of care.
To correct this problem, CMS has created several value-based programs, which reimburse healthcare organizations based on quality outcomes rather than per-patient spending. These programs include:
- Hospital-Acquired Condition Reduction Program
- Hospital Readmissions Reduction Program (HRRP)
- The Hospital Value-Based Purchasing (VBP) Program
- Medicare Access and CHIP Reauthorization Act
- Physician Value-Based Payment Modifier (VM)
- Quality Payment Program
- Quality Payment Program Cost Measures
- Skilled Nursing Facility (SNF) Validation Program
The impact of value-based care on nursing practice
These value-based programs depend heavily on nursing involvement. The Hospital-Acquired Condition Reduction Program measures the rate of pressure ulcers, falls, post-surgical respiratory problems, deep vein thrombosis, and other hospital-acquired conditions.
While the entire healthcare team can take steps to prevent these problems, turning patients frequently, good oral hygiene, fall prevention, and encouraging mobility are all primarily nurse-driven.
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Measuring quality outcomes
Good healthcare organizations aim to increase healthcare quality, improve outcomes, reduce morbidity and mortality, and help patients meet their goals. Researchers and policymakers are constantly seeking ways to benchmark quality care and give helpful feedback to providers.
Like any other goal, healthcare systems must have specific, measurable, and time-sensitive benchmarks to meet to improve their overall performance. The Health Policy Series describes this in detail, stating that health quality indicators must include:
- A quality goal, i.e., a clear statement about the intended goal or objective, for example, inpatient mortality of patients admitted with pneumonia should be as low as possible;
- A measurement concept, i.e., a specified method for data collection and calculation of the indicator, for example, the proportion of inpatients with a primary diagnosis of pneumonia who died during the inpatient stay; and
- An appraisal concept, i.e., a description of how a measure is expected to be used to judge quality. For example, if inpatient mortality is below 10%, this is good quality.
Healthcare reform
Nearly every United States resident, regardless of their political affiliation, socioeconomic status, or occupation, agrees that the country needs to improve the healthcare system. However, strategies and healthcare reform ideas are highly divisive and controversial.
An article published in Investigative Otolaryngology describes the history of healthcare reform and how it might look moving forward, and how it might impact the main stakeholders: the patient, the payer, and the provider.
Researchers describe the Patient‐Centered Care Model, Patient‐Centered Medical Home, Population Health, Personalized Medicine, P4 Medicine, Precision Medicine, Managed Care, and Accountable Care. Each of these models and ideas focuses on improving the quality of care, reducing cost, and holding providers accountable.
As of 2025, there are many proposed changes to healthcare policy. These include several budget cuts, HHS restructuring, price transparency laws, tariffs on healthcare supplies, and added fees for hospital executive functions. In addition, policymakers are attempting to change prescription drug pricing laws, overhaul the Medicare Merit-Based Incentive Payment System, and expand Medicare Advantage plans.
In addition, the Tax Cuts and Jobs Act is set to expire in 2025, giving policymakers an opportunity to make big changes to healthcare deductions and tax credits.
