We talked to executives, clinical leaders, and clinician members of our Insights Council for a closer look at the major obstacles preventing increased value in care.
Understanding the top barriers to improving the value of health care is critical to the transformation of health care delivery. Without clarity about what is standing in the way of value-based care, health care leaders and practitioners will be unable to move forward with clinical practice initiatives and other opportunities outlined in Care Redesign Report: Why Population Health Management is Undervalued.
The top obstacle identified in NEJM Catalyst research to improving the value of care was the fee-for-service payment system, according to 52% of respondents overall, as well as 59% of executives and 63% of clinical leaders participating in the survey. Thomas Yackel, MD, MPH, MS, FACP, CPE, Vice President and Chief Clinical Integration Officer at Oregon Health & Science University in Portland, says that fee-for-service creates a misalignment across health care. “The moral imperative for physicians is to be conservative with the application of health care, while the business imperative is to always do more.” Value-based care, he says, will solve this disparity.
Joel Reich, MD, FACEP, MMM, Senior Vice President for Medical Affairs and Chief Medical Officer at Eastern Connecticut Health Network in Manchester, points out that the fee-for-service system doesn’t align incentives with better long-term health, coordination of care, or managing the social determinants of health. “Fee-for-service says, ‘I did this, so I get paid for this,’” he says. “There is nothing in it financially that would push people to work in a more unified manner.”
He believes reimbursement that is directly tied to care quality, outcomes, and management of the total cost of care will enable alignment of care providers.
Providers should be incentivized to change how they deliver care, he says. In a value-based world, integrated networks would promote healthy eating and activity, use community care managers and home health extensively, and be more likely to take advantage of telehealth, including remote patient monitoring and telepsychiatry, to integrate behavioral health services. “Instead of selling health services, we would truly deliver health,” he says.
Respondents to the NEJM Catalyst survey differed in their perception of the patient role in health care. More than half of clinicians (52%) ranked “lack of patient engagement in improving their own health” as their choice for top barrier. Overall, respondents ranked this as the second greatest obstacle to improving the value of care.
Titus Abraham, MD, an internist at Annapolis (Maryland) Internal Medicine, and the physician manager for the practice, says that while he believes lack of patient engagement is a significant issue, he calls it “a two-way street.” “The role of the doctor has diminished,” he says. “Patients are seeking care from other sources such as the Internet, television programming, and so-called ‘alternative providers.’” Abraham believes the onus is on physicians to be more assertive in finding out why a patient is going elsewhere for care.
“Primary care providers, if adequately knowledgeable themselves, can provide the needed context for information and can provide the needed healthy skepticism and evidence-based thinking to determine the role and value of testing and treatment,” he says.
For instance, when he found out a patient of his who had suffered panic attacks had been consulting other doctors and was scheduled for a coronary catheterization, he asked the patient and his wife to see him first. Abraham recommended the patient see a psychiatrist before the procedure. The patient was later diagnosed with post-traumatic stress disorder rather than cardiac disease.
The third-greatest barrier to improving the value of care, named by 41% of respondents to the NEJM Catalyst survey, was lack of integration of different types of facilities (such as tertiary and community hospitals and non-acute care). Terrill Theman, MD, Adjunct Professor of Healthcare Systems Engineering at Lehigh University, and a former practicing cardiothoracic surgeon, believes that a lack of accountability has hindered care coordination. “When I was in practice, since I was getting the majority of the fee associated with the illness, I made it my job to integrate that patient’s care and get sign-off from all members of their care team,” Theman says. He experienced a fractured delivery system that left patients feeling like no one took responsibility for them. “They need someone who is captain of the ship to make sure everyone talks to one another and that there is a reasonable treatment plan.”
Theman says value-based care makes him optimistic about the future of care delivery, though the rollout has not been perfect. “At least the Affordable Care Act shook the pot and got us working on solutions.”