Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform.
The goals of value-based reimbursement models can be broadly stated as having two goals: deliver care to some agreed upon standard, and reduce/slow healthcare cost growth.
In theory, as these models evolve, physicians who do not meet the criteria could be penalized either through lower reimbursements (downside risk) or removal from certain networks. The implementation of value-based reimbursement models rose to address significant periods of healthcare cost growth outpacing inflation. To date, the actual savings and care improvement have been slower than expected in many cases and, unfortunately, may be exacerbating another healthcare trend: physician burnout.
In a recent analysis of CBO data, Avalere reports that the aggregate ACO savings through the Medicare Shared Savings Program have underperformed projections by around $2 billion. The news wasn’t all bad as the analysis reported that by year four of participation, the average ACO produced savings. In some additional positive news, ACOs in downside risk models performed favorably by generating more savings over the length of the study. While Avalere’s research indicated that these models do produce savings compared to projected benchmarks, the saving weren’t as substantial as expected or projected.
RTI Consulting highlighted additional challenges in effective value-based contracts in their study of the State Innovation Models (SIM) initiatives. The SIM program intends to empower states to reduce costs for Medicare, Medicaid, and private plans through the development and promotion of alignment of alternative payment models. RTI Consulting found several reasons that SIM initiatives haven’t hit the mark.
One of the most relevant reasons being that private payers want to maintain their flexibility and autonomy to do their own thing with value-based payment models. Relevant to this is the finding: on average physicians are contracting with more than seven payers and over one-third are contracting with more than 10 payers. The desire of some payers to keep aspects of payment and data fragmented is one problem the SIM initiatives are facing. This also underscores another rising issue in healthcare: physician burnout.
Scary picture for the future
The incidence of physician burnout has gained more attention, particularly as bodies like the AMA report that burnout rates have risen between 30 percent to almost 60 percent in some specialties, up substantially from 2013. The Agency for Healthcare Research and Quality (AHRQ) studies the five causes of clinician burnout: family responsibilities, time pressure, EHRs, the low pace of control, and chaotic environments. Clinicians are being asked to do more than direct care delivery. While AHRQ’s buckets indirectly reference value-based payments, the next round of survey data will likely highlight financial and varying care standard concerns as major areas for physician burnout.
To date, the consequence of clinician burnout hasn’t been a reduction in care quality but has caused some to leave the field and it is intuitive that at some point the pressure will impact care delivery.
The combined studies by Avalere and RTI Consulting form a potentially scary picture for the future of value-based reimbursement and physician burnout. If it actually takes four years to effectively learn how to succeed in one value-based model and physicians are in between five to seven payment arrangements (let alone 10), the burnout rate can only go up. What will exacerbate burnout rates is how these payments models will evolve to include downside risk.