We talked to executives, clinical leaders, and clinician members of our Insights Council for a closer look at the advantages of moving to value-based care.
To convince a health care organization to migrate across the spectrum from fee-for-service to value-based care, leaders have to identify and promulgate the advantages. What will be the big wins for adopting new payment models?
According to New Marketplace Insights Report: Value-Based Payment Gains Traction Amid Active M&A Environment, respondents are tied at 54% on viewing the top advantage as “payers are insisting on it” and as “it will improve care quality.”
“I would have thought ‘payers are on insisting on it’ would have been the top one — period,” says Laurie Gianturco, MD, Vice President and Chief Medical Officer for Health New England, a provider-owned, nonprofit health plan with 200,000 members in Massachusetts and Connecticut.
The pressure being applied by the Centers for Medicare & Medicaid Services to have 90% of all traditional Medicare payments tied to quality or value by 2018 should be impetus enough, Gianturco says.
But she acknowledges that the value-based discussion is a tough one for many health care organizations. “Hospital systems and providers make money for fee-for-service. That’s not guaranteed in value-based care, and it’s going to be a lot of work,” she says.
In addition, providers will have to take risks and implement evidence-based outcomes and quality measures. “That’s not something they have a strong background in doing,” she says.
Because of these hurdles, she recommends that physicians receive support through the transition. “In these initial [value-based care] models, there is tremendous burden put on physicians. The models are constantly changing, with no proven value to them yet,” she says.
She’s optimistic, though, that value-based care will better align everyone on the health care continuum, improve quality, and control costs.
But Caroline Poplin, MD, JD, FACP, physician at the Arlington (Virginia) Free Clinic, sees a difficult road ahead for physicians because of value-based care. “They won’t have more time for patients; they’ll just have more patients,” she says.
She says the value-based care argument gets complicated when medicine and wellness are intermingled. “What internists like me should be doing is coordinating care . . . not organizing someone’s effort to lose weight.” Wellness efforts can be a poor use of a physician’s education and experience, she says.
The demands of value-based care lead to “a disconnect between the leadership and the clinicians in the trenches,” she says. For example, when an obese person comes in for a cold, a physician has to remember to talk to him about vaccinations and cholesterol, and make sure he is working on his weight and has a living will. “Physicians find this approach much harder and less satisfying,” she says.
Paul Nelson, MD, primary care physician at Family Health Care PC in Omaha, Nebraska, isn’t convinced that value-based care will result in better quality.
“Primary care is not insurable by the standard sense of the word, because so much of what you do is manage uncertainty,” he says.
Nelson, a 40-year veteran of primary care, says there is a lack of connection between the social mandate for basic health care needs and the economic mandate for complex health care needs.
For instance, he prefers to have a registered nurse answer the phone at his practice. “If patients have a change in health, the RN knows who needs to be seen immediately,” he says, adding patients call in a timely way because they trust the RN answering the phone. However, the skill set utilized in answering calls is not reimbursable, according to Nelson.
He thinks new payment models “discount” the primary care physician’s role in health care as well, and that things he can do to help people “are not honored by the system.” Therefore, Nelson has decided to move toward retirement.
One survey respondent, a vice president of practice transformation at a midsized health institution in the South, who asked to not be named, says the retirement discussion has come up a lot. “The quality issue is a personal one for physicians, but there is value in accepting volume measures,” she says.
She wasn’t surprised that only a third of respondents to the NEJM Catalyst survey said that “organizationally and clinically, we are best equipped for” value-based care, because she doesn’t believe most are. While hospital-owned practices will be looked out for and supported by their parent organization, “an awful lot of small practices and solo practitioners might be on the negative payment side at the beginning,” she says.
However, she hopes that insurers will reimburse providers upfront for the infrastructure they’ll need, such as updated EMR systems, care navigators, and access to behavioral health expertise.
“[Value-based payments] are going to hurt and are going to be painful, but everyone has to understand that health care costs were untenable and something had to change,” she says.