By Matt Fisher, Esq
Twitter: @matt_r_fisher
Host of Healthcare de Jure – #HCdeJure
The path to value-based care in healthcare is becoming murky. After a few years of heightened promise and hope, the current and near future reality is not necessarily so promising. Results from innovation programs such as accountable care organizations, bundled payments, and other ideas have not been as rosy as expected while bringing a number of attendant challenges. Those troubles are underscored by the findings from a recent survey conducted by Quest Diagnostics. In fact, the results are called “Stalled Progress on the Path to Value-Based Care,” which puts out the uncertain state without shying away from the perceived truth.
The survey reveals a slide among the viewpoints of physicians and, to a degree, health plan executives about the current state and viability of value-based care. On the whole, physicians are more skeptical. Some of the more interesting results are that a declining number of respondents believed the information necessary about patients to succeed with value-based care was in their hands. Commentary frequently points to data as the lifeblood for being able to move ahead with value-based care. The dim view of data available in a physician’s electronic medical record helps provide color around falling assessment of whether sufficient data are available for success. Only 39% of responding physicians felt the EMR contained all the data needed for value-based care.
If so many physicians feel data are missing, where can that data be found? The cynical response would likely say in disparate systems that cannot talk to each other. While potentially overly cynical, the response is probably not without merit. The lack of interoperability, regardless of how it is defined, is not a myth within the system. While the technological means of remedying interoperability can probably be developed quickly or maybe even already exist, the will or incentive to put it into place is arguably missing.
Related to the data issue is the scope and applicability of quality measures. While this is an overused trope, if the quality measures in one value-based care plan are examined, then the reviewer likely only knows about one set of quality measures. Instead of developing and implementing a common set of quality measures, every value-based care program wants to come up with its own. This result can force providers into “focusing” on potentially hundreds of different quality measures that just sap time and energy from all involved. Per the Quest survey, health plan executives more uniformly believe the measures can be helpful (80%) as opposed to a lower, though still majority, percentage of physicians (68%). While both areas of respondents leave a decent amount of room before all are on board, getting well over a majority for both suggests that quality measures are closer to hitting the mark than not.
Despite the potential usefulness of the measures being seen, both sides were very much aligned around the concept that measures are too complex. As noted above, it feels as though every value-based care program comes with its own measures. There could be five or more means of looking at blood pressure, diabetes management, smoking cessation or any other number of issues. It is not clear why it is or should be so hard to come up with a common set of measures that can apply to any value-based care program. At some level, coming up with a proprietary program is more harmful than helpful.
One insight that can be inferred from the diverging views of physicians and health plan executives is that alignment between different aspects of the healthcare industry remains missing in action. Coming up with and putting into practice the means of getting the healthcare system into a more efficient, quality focused realm cannot be the work of any one segment of the industry. A fragmented approach will only lead to failure.
Could fraud and abuse regulations be a driver for the remaining gap between physicians, other providers, health plans and others in the industry? It is not a theory without merit. The fraud and abuse laws are arcane, convoluted and throw up a lot of barriers. That is why the Centers for Medicare and Medicaid Services’ Request for Information concerning the Stark Law is important. The RFI squarely focuses on value-based care and how implementation and enforcement of the Stark Law can be changed to encourage value-based care. While exceptions arguably exist already that can be used to aid the creation of value-based care relationships, the law is rooted in a fee for service world and driven by concerns that may be alleviated and/or eliminated in a value-based care world.
Arguably CMS has already recognized that the Stark Law is incompatible with value-based care as a result of including numerous waivers with its different ACO models, bundled payment programs, and other innovation models. The waivers, all self-certifying, provide fairly broad exemptions from the Stark Law for participants in order to more easily align workflows and divide shared savings. If the waivers were deemed necessary for the innovation models, it really begs the question of why the same waivers have not been expanded to encourage value-based car experimenting in other areas.
Leaving aside Medicare and other government-based programs, the private industry is not abandoning the value-based care world. Insurers such as UnitedHealth Group are, if anything, expanding such programs. Unlike Medicare, the private industry potentially has more freedom to adjust on the fly and account for issues such as those revealed by the Quest survey.
Ultimately, as has been noted before, the healthcare industry needed to change. The fee for service world could not remain rooted in place as costs were (and possibly still are) uncontrolled. The issue now is whether concerns about the ideas that have been put into place will be addressed and innovation allowed to occur, or will another misaligned system be allowed to pervade the industry.
This article was originally published on Mirick O’Connell’s Health Law Blog and is republished here with permission.