Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

6 ways to smooth the journey to value-based care

Andrew Snyder, MD
Policy
December 7, 2018
Share
Tweet
Share

STAT_Logo I have had the fortune — both good and bad — of being at the forefront of reforming physician reimbursement as an advocate for physicians. I’ve worked on models spanning private practice, group employment, faculty practice plans, and independent physician associations.

It’s been a bruising journey.

There were the old ways — relative value units (RVUs) and other tortured renditions of volume medicine — that created a lingering culture of compression in which the only way HMOs could continue to squeeze out profits over time was to pay less for services. These contrived value units created a system that could reward only a continuous churn of transactional patient visits rather than rewarding improving patients’ health.

In the 1990s, physician reimbursement models inadequately applied the concepts of capitation and risk adjustment. When they resurfaced in the latest value-based-care efforts, they sent physicians fleeing for the door crying, in “Poltergeist”-fashion, “They’re baaaack!”

Considering our pasts, our mistrust of the reimbursement system — of hospital administrations, of academic departmental models, and, of course, of the insurance industry to fairly compensate primary care physicians (PCPs) — is appropriately enormous. Most “new” reimbursement methods remain based in volume, with relatively small incentives for check-the-box successes that don’t truly amount to a paradigm shift toward value-based reimbursement. Those that do adjust payments away from fee-for-service often don’t recognize and reward the value of primary care providers.

These physicians, who are vital links in the chain of health care, have virtually zero control in the current system on how and how much they get paid.

The system has predecided that primary care services are worth approximately 6 cents of every health care dollar. That is a small sliver of the pie in exchange for the expectation of being patients’ care quarterbacks across multiple clinical caregivers— and even more egregious should the primary care role evolve, as is logical, into also quarterbacking cross-community social determinant and wellbeing initiatives in addition to providing clinical care.

I have heard the gripes and met the resistance over the years from insurance plans, systems, hospitals, and physicians. I have also been able to help develop and implement progressive physician compensation models that appropriately reward physicians not just for treating those who walk in the door but for collaborating on treatment models that encourage fewer people to walk in the door — models that truly encourage cross-caregiver collaboration and reward value in medicine rather than volume. These have proven themselves to offer much larger upside potential for primary care physicians than the ceiling we’ve already hit on speed and volume.

In every flavor of payment models I have worked with, I’ve had to assume I cannot change the insurance industry. But I can affect the spoons that actually feed us as physicians, especially as more physicians become affiliated or employed.

In working with leading providers in New York, California, and other states in between, I’ve learned after many arguments that most compensation methods are currently misaligned, meaning they pay physicians for transactional, volume-based care but they ask those physicians to practice value-based health care. Properly aligning compensation with work is the key, but that means many things to multiple stakeholders, all with varying expectations and timelines.

Alignment between pay and care occurs when physicians are rewarded for activities that promote their patients’ overall health and wellness and for managing chronic disease. In an aligned pay-care scenario, physicians are rewarded when you don’t have a heart attack, not when you do. Wrapping one’s head and one’s payment system around such a concept is a challenge.

When alignment isn’t achieved, we end up sliding back to the familiar: The devil you know is better than the devil you don’t, and volume-based addition is at least easy to understand and administer.

From multiple attempts to engineer value-based care models that value primary care physicians, here are six lessons I’ve learned.

ADVERTISEMENT

One question matters. The only question that should ultimately matter to primary care physicians is this: “For how many risk-adjusted patients are you providing high-quality care?” The new widget in town is the holistic person, not an RVU or an evaluation/management code.

The rules of the game must change. Primary care physicians got really good at the volume game. We learned to play by the perverse rules handed to us by HMOs. This isn’t a pejorative statement — playing the game was protective. I am confident that when we all understand the new rules for creating value in health care, we will learn how to succeed there, too. Yet the upside should not have an arbitrary ceiling. A piece of the savings that primary care providers help generate should be reserved for them. The same percentage of a bigger pie is, well, more pie. The burnout factor for doing more for less is real. We can change this.

Adequate risk-adjustment is an absolute. Risk adjustment is a lesson from the 1990s that still haunts us. Stratifying patients only by age and sex does little to indicate the cost of care. Primary care physicians were unable to provide the time that very sick patients needed, and this poor risk adjustment was the inherent driver of cherry-picking patients. With data-informed risk stratification and risk adjustment that account for social determinants of health as well as treatment across providers, we can actually entice physicians to reach for the sicker and frailer by rewarding them for doing so.

Change practice operating models. Incrementalism may not only slow us down, it may cause us to fail. Value-based care is about more fluid communication, prevention, reminders for adherence, and at-the-time help, not episodic, infrequent, and fragmented interaction. But new tools are needed to support these new workflows and improved access to wraparound services. Quarterbacking cannot be conflated with just doing more. And that means we’ll need to build new compensation models that reward the outcomes we all seek for our communities.

Weatherproof the cracks. Problems will occur, so arm yourself with the tools to fix them. Success in newer models requires clinical informatics as well as population- and patient-level analytics to maximize the efforts of everyone on the care team and ensure few-to-none fall through the cracks.

Trust is the final frontier. Innovative reimbursement methods require a level of transparency that most payers have been unwilling to share. Transparency is a contractual must. I always say, out loud and often, that if primary care providers do not perceive absolute transparency into data and methods, then they shouldn’t agree to a contract with the payer. Don’t trust the negotiators, no matter how nice they are. Trust the numbers.

Like many physicians, I know the post-traumatic stress disorder generated by 1990s capitation. But times are different. We now have far better data and analytics; we can adjust risk to provide for increased payments for patients who have overlapping conditions that complicate treatment, or whose age or disease progression make them more expensive to treat. Current capitation methods allow for fairer environments in which to run a primary care practice, and for the potential to increase revenues by addressing existing systemic inefficiencies.

Ideally, our health care system would do a better job at keeping people healthier. But since that means that the market for primary care physicians would shrink considerably, then those physicians can achieve higher pay only through greater efficiency. And that means we need to find a better path forward for physician reimbursement.

Andrew Snyder is chief medical officer, Evolent Health. This article originally appeared in STAT News.

Image credit: Shutterstock.com

Prev

There's a good reason why we don't see patients' joy in the office

December 7, 2018 Kevin 0
…
Next

3 common complaints patients have

December 7, 2018 Kevin 6
…

Tagged as: Primary Care, Public Health & Policy

Post navigation

< Previous Post
There's a good reason why we don't see patients' joy in the office
Next Post >
3 common complaints patients have

ADVERTISEMENT

Related Posts

  • Primary Care First: CMS develops a value-based primary care program for independent practices

    Robert Colton, MD
  • The promise and challenge of integrating primary care into community-based mental health centers

    Betty Rabinowitz, MD
  • Direct primary care is an answer to volume-based insurance reimbursement models

    Troy A. Burns, MD
  • The expanding role of specialists in value-based care

    Martin Lustick, MD
  • How pharmacy-based primary care takes the low-hanging fruit

    Charles Dinerstein, MD, MBA
  • To “fix” health care delivery, turn to a value-based health care system

    David Bernstein, MD, MBA

More in Policy

  • How American medicine profits from despair

    Jenny Shields, PhD
  • What I learned about health care by watching who gets left behind

    Maanyata Mantri
  • How the One Big Beautiful Bill could reshape your medical career

    Kara Pepper, MD
  • Why the U.S. Preventive Services Task Force is essential to saving lives

    J. Leonard Lichtenfeld, MD
  • Brooklyn hepatitis C cluster reveals hidden dangers in outpatient clinics

    Don Weiss, MD, MPH
  • Why nearly 800 U.S. hospitals are at risk of shutting down

    Harry Severance, MD
  • Most Popular

  • Past Week

    • Could antibiotics beat heart disease where statins failed?

      Larry Kaskel, MD | Conditions
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician
    • Why palliative care is more than just end-of-life support

      Dr. Vishal Parackal | Conditions
    • When life makes you depend on Depends

      Francisco M. Torres, MD | Physician
    • Guilty until proven innocent? My experience with a state medical board.

      Jeffrey Hatef, Jr., MD | Physician
    • Why medical notes have become billing scripts instead of patient stories

      Sriman Swarup, MD, MBA | Tech
  • Past 6 Months

    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • COVID-19 was real: a doctor’s frontline account

      Randall S. Fong, MD | Conditions
    • Why primary care doctors are drowning in debt despite saving lives

      John Wei, MD | Physician
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • mRNA post vaccination syndrome: Is it real?

      Harry Oken, MD | Conditions
  • Recent Posts

    • How value-based care reshapes kidney disease management for better outcomes [PODCAST]

      The Podcast by KevinMD | Podcast
    • Imagining a career path beyond medicine and its impact

      Hunter Delmoe | Education
    • What is professional identity formation in medicine?

      Adrian Reynolds, PhD | Education
    • A step‑by‑step guide to crafting meaningful research questions

      Julian Gendreau, MD | Physician
    • When recurrent UTIs might actually be bladder cancer

      Fara Bellows, MD | Conditions
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 6 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Could antibiotics beat heart disease where statins failed?

      Larry Kaskel, MD | Conditions
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician
    • Why palliative care is more than just end-of-life support

      Dr. Vishal Parackal | Conditions
    • When life makes you depend on Depends

      Francisco M. Torres, MD | Physician
    • Guilty until proven innocent? My experience with a state medical board.

      Jeffrey Hatef, Jr., MD | Physician
    • Why medical notes have become billing scripts instead of patient stories

      Sriman Swarup, MD, MBA | Tech
  • Past 6 Months

    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • COVID-19 was real: a doctor’s frontline account

      Randall S. Fong, MD | Conditions
    • Why primary care doctors are drowning in debt despite saving lives

      John Wei, MD | Physician
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why pain doctors face unfair scrutiny and harsh penalties in California

      Kayvan Haddadan, MD | Physician
    • mRNA post vaccination syndrome: Is it real?

      Harry Oken, MD | Conditions
  • Recent Posts

    • How value-based care reshapes kidney disease management for better outcomes [PODCAST]

      The Podcast by KevinMD | Podcast
    • Imagining a career path beyond medicine and its impact

      Hunter Delmoe | Education
    • What is professional identity formation in medicine?

      Adrian Reynolds, PhD | Education
    • A step‑by‑step guide to crafting meaningful research questions

      Julian Gendreau, MD | Physician
    • When recurrent UTIs might actually be bladder cancer

      Fara Bellows, MD | Conditions
    • How restrictive opioid policies worsen the crisis

      Kayvan Haddadan, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

6 ways to smooth the journey to value-based care
6 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...