It’s impossible to follow health care news without realizing that value-based care is the new watchword. In the ever-expanding effort to reduce health care costs, the hopes of the American health care system seem to rely on the success of this popular concept — that by increasing value for the patient, organizations and individuals can enjoy better outcomes at lower costs. The theory has been a reaction to and criticism of traditional, fee-for-service care. Fee-for-service, so it goes, incentivizes the assembly-line type care and high-cost procedures that characterize the American health care system — at the expense of time-intensive but lower-cost interventions, like investment in primary care. Paying doctors based on outcomes rather than the number of patients seen or procedures performed shifts the incentive to performance rather than volume — potentially to the benefit of patients.
I was formally introduced to value-based care almost a decade ago as a medical student interested in primary care. Still, the seeds of my interest were probably planted in childhood. My father is a primary care physician, and growing up I recall many interactions he had with patients in the community and his dedication to them. In many ways, this approach is from the past. I remember the stacks of paper charts, dictaphones, and pagers that have since disappeared from clinical practice. But what I remember most about his example was how he always gave his patients plenty of time. Like many children of medical parents, I went to medical school, intent on being a primary care doctor like him. As I progressed through my training, I recognized that doctors who felt rushed to see as many patients as possible seemed less satisfied with their jobs — and their patients noticed it as well. Value-based care, in a way, seemed like a solution to this problem — being paid based on how my patients did rather than how many I saw daily made intuitive sense.
The idea of value-based care is not new. Those practicing before the turn of the century, like my dad, are likely overly familiar with the emergence of HMOs, managed care, and capitation in the 1970s, ‘80s, and beyond. However, the current push for value-based care feels different. CMS and insurers have implemented initiatives to accelerate this “transition” in care from a traditional fee-for-service care delivery model. There’s money to be made — and lost — by participating in these models. As I quickly learned in my first few years of practice, fee-for-service reimbursement hasn’t kept pace with expenses or inflation, and running an insurance-based practice is incredibly difficult even without paying some attention to achieving shared savings targets or quality bonuses. In this declining reimbursement environment, even those who historically have shied away from value-based arrangements find themselves unable to ignore value-based care by economic necessity — whether forced by their employer to care, or voluntarily participating to stay afloat.
This flirtation with value-based care as merely a way to raise revenue is the source of many of its problems and critics. Value-based care is intended to be disruptive. The devil of what constitutes value lies in the details, which need to be measured. Success in a value-based care model depends on robust data and reporting infrastructure — quality metrics, patient satisfaction scores, and risk adjustment take center stage. Ideally, this data gathering allows for new initiatives and identification of patients who slip through the cracks and provides insights into ways to take better care of them. More often, only lip service is paid to collect and improve this data, resulting in only minor tweaks that essentially preserve the status quo — much to the frustration of physicians left feeling like glorified data-entry clerks, clicking checkboxes to certify “meaningful use.”
Why does this occur? Examining how we got here may be illustrative. Fee-for-service medicine prioritizes throughput above all else. Health systems and individual physicians have thrived for years by creating highly tooled environments to support volume over value. However, under value-based care arrangements, operating in the same systems that drove success in the past may not guarantee success. Quality that was previously taken for granted must now be proven with data. Clinicians with high volume, specialists who make a living from higher-cost procedures, and hospital systems that rely on driving referrals to high-reimbursement services all stand to lose money if they can’t show their work. This is not an easy pill to swallow, especially if you consider the “low performers.” Rather than considering whether there is truth to the data, it is easier to simply add another checkbox, run another report, and in general spend a tremendous amount of activity proving that the current system is the perfect one, after all.
With burnout on the rise and physicians considering leaving the profession in droves, it seems the preference for propping up the status quo over embracing discomfort has failed to deliver on the promise of value-based care. The difficult truth that most are realizing is that it is impossible to “do value-based care” and maintain the status quo. Clinicians simply do not have the time, nor do they go to school, to upload individual colonoscopy reports to receive “credit” for work already performed and maintain the same clinical workload. These tasks must either be offloaded or eliminated for the work to be sustainable. This requires actions like hiring additional staff, reducing the number of patients seen daily, and investing in data infrastructure. None of these things are a priority under a system that aggressively prioritizes referrals to high-reimbursement services. For it to be successful, VBC must be a focus, not an afterthought, and physicians must be supported to perform well in these models. Anything less will engender well-deserved physician hostility or outright ridicule.
If we want our endless clicks and measurements to mean something, we must re-examine the motivations behind participation in such models. I propose three simple rules that have been tremendously effective in implementing value-based innovation in my practice.
First, quality metrics to pursue and improve must be driven by front-line clinicians. I have found that there is no buy-in for transformation when initiatives are defined by insurance companies, administrators, or any other party when these are generally not the people doing the work. Second, support staff to drive value-based innovation must be embedded at the point of care delivery to support change. Without dedicated staff to drive change at each level, quality and value-based transformation is “just another thing” the busy clinician needs to fit into their schedule. Third, de-implementation must be as much a focus as implementation. I have been involved in far too many projects where we find ourselves asking months after the fact why we are still asking specific questions of patients, only to find that the “required” data element we are collecting is no longer being used in any meaningful way. By ruthlessly eliminating unnecessary data collection requirements, more time can be spent on promoting projects and improvements that better serve patients. Like all changes, implementing these rules can be painful. This should not be discouraging but seen as a sign that change is necessary.
If systems and physicians can navigate these challenges, the rewards for patients — and perhaps physician practices — may be nothing short of transformative. As a primary care doctor who has experimented with the model, I’ve seen the impact of what having time for a home visit can do for an elderly patient just out of the hospital and how fast certain conditions can be resolved with a quick portal message rather than a trip to the ER. While taking the extra time to do these things doesn’t “pay well” financially, it’s the kind of thing that’s essential to building a therapeutic relationship as a primary care doctor. Value-based reimbursement enables this kind of care — the kind I watched my dad provide when I was young — and stops me from constantly keeping one eye on the clock and one eye on the keyboard when working my way through the clinic. While it certainly is different, different hasn’t been bad.
On balance, I think that physicians who embrace the challenge of this new model may find themselves and the systems in which they work more capable of delivering the high-quality care that patients deserve. Imagining a world where our insights and data translate to meaningfully better patient outcomes ought to be the goal for all of us in health care. The challenge of meaningfully gathering data merits attention, but it should prompt us to question and improve how we measure and report value, not resist it. Are we willing to think differently and meet the challenge of value-based care? I believe that we are — and that, as physicians, nobody is better poised to tackle this problem — if only we are willing to let go of older models of thinking that serve us more than they serve patients. Seizing the moment requires seeing the transition to value-based care not as a threat but an opportunity. If we can do that, we have nothing to fear apart from stepping out of our comfort zones. Getting comfortable with being uncomfortable in health care is a skill many of us learn to exercise daily, whether when having a difficult conversation with a patient or in training while stretching our clinical skills. The transition to value in reimbursement shouldn’t be any different.
What has been your experience with value-based care? Share in the comments.
Dr. Brennan Kruszewski is an internal medicine physician in Hudson, Ohio. He is passionate about transforming primary care. He enjoys spending time outdoors, especially biking the trails of Northeast Ohio. He is active on social media, and blogs at his personal website. Dr. Kruszewski is a 2024-2025 Doximity Op-Med Fellow. Opinions expressed here are his own and not the opinions of his employer.Image by Jonathan Evans / Gettyimages
