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Experts offer suggestions to improve value-based care at national level


House subcommittee holds hearing on best ways to shift from fee-for-service for treatments, to incentivizing better health for patients.

© U.S. House of Representatives

A panel of experts prepares to testify before the “Hearing on Improving Value-Based Care for Patients and Providers,” convened June 26, 2024, by the Health Subcommittee of the House Ways & Means Committee. This screen shot was taken from the webcast of the hearing.
© U.S. House of Representatives

Value-based care can make Medicare patients healthier while sustaining physicians’ practices, but it needs fine tuning within the U.S. health care system to optimize outcomes.

A panel of experts shared their opinions in the “Hearing on Improving Value-Based Care for Patients and Providers,” convened June 26, 2024, by the Health Subcommittee of the House Ways & Means Committee. Representatives, physicians and an administrator exchanged their views about what works to help patients, and a lot that could be better.

“Simply put, the current system, fee for service, that model in health care is not working,” said Subcommittee Chair Rep. Vern Buchanan (R-Florida). “Paying for each medical service without regards to patients’ outcome leads to inefficient care delivery, providers burnout and no improvement on patients’ care. This is not the way health care should be delivered in our country.

“In contrast, value-based care emphasizes providing actual quality care to the patient while improving their health outcome, healthy outcomes, and generating savings instead of incentivizing and paying providers based on how many patients they see through a given day,” he said.

In 2023, just 17% of physicians and other providers participated in a value-based care program under traditional Medicare, while some studies showed up to 40% of physicians and providers used value-based care programs for Medicare Advantage, Buchanan said.

“If implemented correctly, value-based care will lead to lower health care spending costs and a healthier life,” he said.

Rural health problems

Currently, rural health care is the biggest health inequity in the nation, said Sarah Chouinard, MD, chief medical officer of Main Street Health, and a longtime physician in rural West Virginia.

“The problem with health care in rural America is not the physician community. Rural doctors are bright and focused and committed. They love their patients. They're pillars of their communities and very invested,” Chouinard said.

“The problem is that it is too hard in rural communities to execute on their care plans,” she said. “We have an opportunity before us with value based care to build a model that addresses this key challenge.”

Chouinard gave the example of a patient with chronic obstructive pulmonary disease, treated with a nebulizer. That patient needed medical help, but also needed an extra set of hands to navigate his utility bills to restore his home’s power, allowing him to control his chronic condition and stay out of the emergency department.

“Focusing on these types of nonmedical needs is essential to improving the health outcomes in rural areas,” she said.

Secondly, physicians need flat payments per patient to have upfront, reliable revenue to take on risks of value-based care arrangements. Physician practices need to integrate value-based care programs with existing electronic health records; they don’t need new mandates for new technology, Chouinard said.

Ways to help VBC

Legislators could do at least four things to help physicians integrating value-based care models, said Stephen Nuckolls, CEO of Coastal Carolina Health Care PA and its accountable care organization (ACO), Coastal Carolina Quality Care, in eastern North Carolina.

Continue advanced alternative payment model (A-APM) incentives. The 5% A-APM bonus was a crucial incentive for his physicians’ practice.

Address incentives across the continuum of care. Many people refer to accountable care organizations as primary care models. Primary care performance is critical, but groups will find higher levels of qualities and savings when physicians across specialties work together.

Remove regulatory burdens. ACOs are subject to the same coding reviews as practices not participating in value-based care, but should be exempted from controls over the fee-for-service model.

Ensure programs that are successful can stay in value-based care programs. His organization’s value-based care contract is unlikely to be renewed because as programs perform well, benchmarks are lowered, and the U.S. Centers for Medicare & Medicaid Services has not addressed that benchmark ratchet.

Making money when patients are sick

When considering value-based care, health care executives across the country said they make money when patients are sick, not when they’re healthy, said Mathew Philip, MD, internist and interim value-based care chief medical officer of Duly Health and Care in Illinois.

Philip used the example of his father’s diagnosis with an aggressive kind of leukemia – and dealing with a health system geared toward sending patients to emergency rooms and hospitals. His father recovered, but not every patient has that happy ending, he said.

Lawmakers and the health care system must address greater alignment, a reduced regulatory burden, and better data sharing to create incentives for physicians and other clinicians to participate in value-based care, Philip said. When physicians spend too much time checking boxes on a computer screen, it erodes the trusted bond with patients that “is the bedrock of achieving great outcomes in health care,” he said.

Regulatory burdens also slow down or stop new and innovative programs. Philip used the example of Duly Health and Care’s paramedic group, approved in Illinois, to meet and treat patients at home, instead of waiting for patients to show up at the hospital.

‘Conceptually flawed and operationally dysfunctional’

Robert Berenson, MD, an internist who has worked in private practice and in public policy making, said he would declare some contrarian views. Value-based payment as outlined in the Affordable Care Act and the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act has not succeeded in improving quality. “Pay for performance has proved both conceptually flawed and operationally dysfunctional,” he said, and it needs a thorough evaluation and reformulation.

Congress and CMS also must address serious flaws in the Medicare Physician Fee Schedule. “Currently, the fee schedule produces too many technically oriented services and not enough time spent by clinicians in all specialties with patients in diagnosing, explaining, counseling and in managing care, especially for patients with multiple serious chronic conditions,” he said.

Meaning of value

A primary challenge in implementing value-based care is that lawmakers, physicians and patients struggle over what value really means, said Health Subcommittee Ranking Member Rep. Lloyd Doggett (D-Texas).

He offered a scathing review of Medicare Advantage, which was supposed to provide great value by expanding beneficiary choices, reducing health inequities, and saving taxpayer dollars. Instead, Medicare Advantage costs an average of 22% more than if the same beneficiaries had stayed in traditional Medicare, Doggett said.

Some estimates range as high as $83 billion in wasted taxpayer dollars this year, enough to provide hearing and vision coverage to beneficiaries struggling with hearing or vision loss, Doggett said. Medicare Advantage interferes with the doctor-patient relationship through burdens of prior authorizations, step therapy, and other management tools, he said.

Doggett also called for more attention to the Medicare Physician Fee Schedule and to the underpayment of primary care physicians who offer some of the most important and high-value preventive care.

Doctors do what’s right

In the Capitol, when diving into issues of health, it appears there are a lot of really bad doctors that are doing bad things all the time. “We better crack down on them, we better make sure they’re doing the right thing,” by incentivizing good outcomes, said Rep. Brad Wenstrup, DPM (R-Ohio).

But that’s not how it was when he practiced medicine in Cincinnati.

“The threat of malpractice is enough for you to adhere to community standards and do the best for your patient, because you're an entrepreneur, and the only way your business grows is by taking care of people and doing it well,” Wenstrup said. “We have gotten way too involved, way too involved, and I understand the value of positive outcomes. That's how your practice grows. I never cared what Washington thought.”

Instead, Wenstrup said he focused on what his referring doctors and patients thought, and his reputation in the community.

“That’s what drove good outcomes. Nothing Washington did had anything to do with those successes, and we in medicine today do not put enough value on the healthy human life,” he said. “That’s where the savings comes in, is the healthy human.”

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