Value-based care is everywhere. It is really having a moment right now. It has taken on many forms, from the Medicare Advantage home care models to the employer-based direct primary care, but certain aspects of it remain consistent across all delivery forms. Physicians or physician organizations are expected to meet certain expectations and patient outcomes in order to show the value of the care they provide.
In theory, pinning reimbursement rates on good outcomes would therefore incentivize programs and providers to do better work, which is a good thing. But where does the buck stop? As the old adage goes, you can lead a horse to water, but you cannot make it drink. I have seen it time and time again. The physician can only remind a person to go get their mammogram or colonoscopy so many times, to be compliant with their medication, or offer alternative options or order a Cologuard for anyone eligible for screenings. We are still caring for autonomous beings here, who make their own decisions. There will always be some who choose not to follow medical advice, and it is of no fault of the ordering physician, just a fact of that individual’s life that they will not get a mammogram done. A physician can only act as a counselor or guide, not a puppet master.
As these programs continue to expand into a larger portion of the market share, one can only hope that the decision-makers at the Centers for Medicare and Medicaid are looking to what the future will hold. It could go multiple ways; without proper eyes on the horizon, it may lead to more red tape, more bean counters making medical decisions, and less autonomy in medical practice. Hopefully, those in the planning stages for the implementation of value-based care models have a plan for when care providers have met their value metrics at a reasonable expectation and cannot, through their own work, make their patients any better.
If these organizations do not have a reasonable understanding of what percentage of the population will actually comply with medical advice and recommendations, they could and will continue to demand more and more. Research is needed to assess what thresholds are feasible within the current medical system. Limitations outside of patient preference will also prevent making a 100 percent threshold for compliance. In an expensive and disjointed health care system, one cannot expect everyone to be able to complete appropriate medical care when social determinants prevent patient access to proper medications, and when insurance coverage is poor for first-line recommended drugs, and the cost is too high, we cannot reach the gold standard.
Anna Gladstone is a family physician.
