VBC Can’t Work Without Specialists On Board

Did You Know? 53% of orthopedic surgeries performed are useless (meaning they didn’t work or were unnecessary). From meniscectomies, to lumbar discectomy, to knee replacements and more, the results just aren’t there, according to an article in a British Medical Journal on the topic, and an article in the New York Times.

Did You Know? Nearly 70% of emergency visits are not considered actual emergencies, according to a UnitedHealth Group report. These visits, overseen by specialists in emergency medicine, cost approximately $47 billion each year.

Despite the promise—and positive proof that it works—value-based care (VBC) isn’t being applied across the board. In most specialty settings the incentives simply aren’t in place to reward caregivers for outcomes, not pay them for volume.

Fifteen years since VBC began to prove itself in the marketplace, healthcare costs are still rising, needless procedures continue to be performed, and patients often don’t get the care they deserve.

Disconnections between and among providers, payers, and patients are still contributing to inefficiencies across healthcare settings. Complexity in the medical market prevails, and chaos persists.

Why the Disconnect?

There’s one good reason for the seemingly slow pace of the VBC trajectory: To date, value-based care principles are mainly applied in primary-care settings.

• In PCP settings, VBC is a proven concept: Primary care doctors have long been incented to deliver better quality care at lower cost—and they do.
• The problem is, only 10% of care is delivered by primary care providers.
• The remaining 90% is provided by specialists who, for the most part, are stuck in the fee-for-service paradigm. They are used to getting paid based on volume of services provided (rather than results achieved), and that’s the way their practices are set up.

Specialty providers experience by far the most healthcare encounters—and they account for a continually increasing share of total expenditures, according to an article in the Harvard Business Review. Spending on specialty care is up 30 percent, while spending on primary-care office visits is down by six percentage points.

Why the Shift?

A variety of forces are at work now to account for the growing imbalance:

• Primary-care physicians are encouraged to optimize efficiency via value-based care. VBC programs put processes, technology, and data insights to work to everyone’s advantage—including the patient, provider, and payer. Instead of rewarding doctors based on the quantity of services performed or the number of tests ordered, VBC is enabling PCPs to benefit financially by improving patient outcomes.
• Specialists are increasingly on the front lines, delivering services, and accepting payments based solely on volume. Patients are for the most part able to choose to use specialty doctors on their own accord, without a referral. Since, unlike primary care doctors, most specialty doctors are still working under the old paradigm, they’re paid based on number of services provided, each of which has a fee associated with it.

The fact is, when providers are paid based on volume (which specialty providers are), they are incented to order more services. When they are paid based on outcomes (which PCPs are), they are incented to impact outcomes. That is reason enough why specialists need to be brought into the VBC fold.

It’s imperative now that specialists receive appropriate incentives to provide the cost-effective and high-quality care that everyone deserves. Motivating actions and outcomes—like our healthcare system has done in the primary care space—is what it will take to deliver care efficiently and effectively across the board.

Quality vs. Quantity – The Choice Is Clear

The promise of value-based care packs a big punch. By rewarding all providers for quality outcomes (rather than volume of services provided) everybody benefits: Patients are healthier, providers stay focused on performance (rather than payment), and payers operate more efficiently by putting the right incentives in place to encourage providers to practice more efficiently.

Bringing the nine in 10 physicians who are specialists into the world of value-based care is what it will take to move healthcare in the direction it needs to go.

This article is one in a series that advocates the need to bring specialty care under value-based care payment models. Click here to read the next article, CMS Innovation Center: Specialist Incentives for Value-Based Care.

References

Why Aren’t Value-Based Payment Models More Successful? A Failure To Confront Market Dynamics

BCBS North Carolina’s value-based care model has saved members nearly $500M in 3 years

The BMJ Chimes in on the “Scandalously Poor” Evidence for Orthopedic Surgery

Why ‘Useless’ Surgery Is Still Popular

Putting an end to unnecessary ER visits: How this company is lowering healthcare costs