Value-Based Care Lacks Value

The term value-based care, even with the promotional tag promoting prevention, is another iteration of a very old and very tired theme. In the last sixty years there have been at least a dozen “new ideas” with new names for reducing healthcare costs, but with the same old tired and ineffective results. Sadly, every one of these new approaches fails to do what they claim to do. Not one of these attempts to control the cost of healthcare (assessing value, depriving care, and restricting access) has actually cut the continuing increase of the cost of U.S. medical care.

Once again, with the new name "value-based" care, we are being told this new approach to controlling costs will work. And once again, it will not work. Just exactly how many more times are we going to go through failed ways to reduce healthcare costs and instead see the cost of medical care increase and the access to healthcare decrease? My guess is the real methods to reduce healthcare costs won't surface any time soon.

Thirty-five years ago when we wrote our book Modern Medicine: What You're Dying to Know, we wanted to explain that the cost of medical care should never appear in the same sentence as the term value. Budget management should have no place in the same sentence, the same paragraph, or the same book as the quality of physician care for patients. The choices our legislators have made trying to provide affordable medical care haven't worked. It's time legislators stop trying to save medical costs by beating up doctors.

Once again, we are seeing the ugly head of another new phrase for reducing healthcare costs—value-based medicine. Only people who have no comprehension whatsoever of what happens in the exam room would try to connect the value of the visit to price. All the attempts to assign value to a physician's visit with a patient will fail even if the label "value-based" is waved in the air.

Healthcare is not something consumers shop around for as if they were buying a washing machine. Health care is something we all need when we are sick. When we are sick, we need to be able to go to the doctor and get treatment. A doctor who knows us and our history so the treatment fits our particular circumstances. No two people are alike, especially when it comes to healthcare.

The practice of medicine is the only profession required to provide some sign of legislatively defined benefit. Whether you are a judge, an attorney general, legislators, governors, and state and federal employees, you are paid for you services without having to demonstrate any benefit to the community.

As I’ve said before, it’s difficult to even describe value because value is personal and vague. Treatment which works with one patient may not work with another.

The recent focus on emphasizing preventive care is really an attempt to make a nice checklist of things for billing. Payment for examining a patient and determining the cause of illness can't be turned into a neat list of physical actions associated with a convenient charge code. Various services such as vaccinations, screenings for cancer or diabetes, and counseling on topics such as healthy eating, smoking cessation, and weight management provide simple ways to document what physicians do in an office visit. Other examples include well baby visits, routine vaccinations, and screenings for conditions such as high blood pressure, diabetes, and cholesterol.

After spending 45 years in healthcare and navigating through almost any and every situation there is to face, I am left with trying to understand what any of the administrative interference in my practice of medicine accomplishes. The CEO is telling me to see more patients in less time and to only allow one topic per visit. Then, of course I have to deal with the electronic medical record, which for the most part is genuinely user hostile besides requiring hundreds of clicks per visit.

The real problem here is once you jump through all the so-called preventive care options and so-called healthcare services aimed at preventing illness and go through all the hoops trying to find information needed in the electronic record, your patient's 15-minute visit is over. You might have one minute left to try to figure out why the patient is sitting there across from you. At the same time your patient is wondering why you’re not addressing the real reason for the clinic visit. And if the patient's problem is complicated, your only choice is to steal time from the next patient who will be sitting in another room thinking you’re late because you’ve been drinking coffee or managing your stock market portfolio.

I checked Dr. Google to see how preventive care is defined to see if there's something on the list that physicians haven't supplied for the last 80 years. Any physician knows there's nothing new on this list.

• Early detection and prevention can significantly reduce the risk of developing serious health problems.

• It can lead to better health outcomes and a higher quality of life.

• Preventive care can also reduce healthcare costs by preventing or delaying the need for more expensive treatments.

• The American College of Preventive Medicine (ACPM) states that practitioners in this specialty combine skills and experience in clinical care and public health to support the transformation of health systems and rebuild them based on the prevention of disease, injury, and death.

The list makes it look as if these services weren't already provided in an office visit. I know they were, at least in my clinic. The biggest problem to overcome in any patient visit is time.

Furthermore, prevention has been built into prenatal care for the last 90 years. There are a few missing opportunities for prevention in this list. There’s no discussion about how long postpartum care should last. Most other developed countries provide postpartum care for 12 months after delivery. We could make lives much better and prevent many deaths from suicide, homicide, drug overdose, bleeding, infection and heart disease if in this country we continued postpartum care for a year.

Another problem we have is that medical care tends to be territorial. Today obstetric care ends with the last postpartum visit at six or 12 weeks. When I was practicing, these moms, dads, and children were welcome to attend all prenatal visits in my clinic, so I was able to build significant continuity built int my practice. Women didn’t suddenly stop coming to my office for Pap smears.

Today much of obstetric care is like walking a plank. Moms and dads are sent home from the hospital after a birth not knowing what to do and care ends somewhere between 6 and 12 weeks postpartum. They are supposed to find a family practice doctor or some other kind of provider who has no personal investment in them. The woman has no relationship with a physician who knows her history to help prevent suicide, homicide, drug overdose, infections, heart disease and bleeding to death, all conditions which plague postpartum mothers. Other developed countries provide 12 months of postpartum care. And surprise, surprise! These other developed countries have a maternal death rate of 2-3 per 100,000 births. Not the U.S. maternal death rate of 32 per 100,000 births.

A lot of lip service is paid to preventive care. But it's the expertise of a physician in caring for patients which can't be put into some concrete, billable code. Years ago, Hubert Dreyfus wrote Mind Over Machine. At that time there was a lot of going back and forth about whether "expert systems" should be built from the top down or the bottom up. Some thought you merely asked experts questions about their professions and put the answers into the expert system. Hubert Dreyfus argued that novices followed rules, but real experts do not. Real expertise consists of remembering a single incident of something that happened 30 years ago. Consider this. If real expertise is based upon recalling past events, even a single occurrence, this expertise never makes it into an electronic medical record and hence never makes it into AI or check lists. Think about it. The computer never sees the real basis of physician expertise. Everyone knows the medical field is becoming more and more rule-based even though anyone with any reasonable understanding of medicine “knows” that the practice of medicine requires higher level thinking skills than following tidy rules alone. Rules alone simply generate cookbook medicine.

Our horrendous compulsion to try to control the uncontrollable by labeling something right or wrong—even if it doesn’t work— goes right on marching. Government regulations continue to generate rules which demand novice adherence at the expense of expert intuition, strangling the ability of physicians to provide the very quality medical care the “rules” are supposed to guarantee.

We have government agencies, insurance companies, large private equity healthcare companies such as United Health Care, large hospital organizations, all providing their input in threatening ways. These organizations are after the Holy Grail of saving money by limiting care and denying access to care.

We are already well on the yellow brick road to lousy medical care based on rules, regulations, and penalties to physicians who step outside the box—which is, by the way, the known marker of expertise. No rule-making grid enforced by physician penalties is going to correct what cannot be corrected with rules. It’s time for regulators and payers to return to physicians their ability to treat and diagnose their patients based not only upon rules, but also upon their expertise. The financing of healthcare and the value of healthcare are two entirely different beasts and should never be placed together in the same sentence, paragraph, page, or book.

If we want to control the cost of medical care, it can easily be done but you have to want to do it. The amount of money that insurance companies, private equity hospital corporations, as well as "non-profit" hospitals suck out of the healthcare budget every year is astronomical. You cannot expect these entities to work to reduce their profits.

Why the legislators and the Center for Medicare and Medicaid Services (CMS) don’t beat up the corporate entities draining our healthcare budgets is very difficult to understand. To me, it appears physicians are low hanging fruit, easy to blame and easy to prosecute.

When it comes to healthcare, cost and value can never meet. Repairing finances and saving billions of taxpayer heathcare dollars per year is a slam-dunk, easily done with one year of effort and application if legislators did their job.

We will never balance the healthcare budget on the backs of the care provided to patients by physicians. Our current system has for many years worked best by depriving care. That’s the main reason that we pay more for medical care than any country in the world, and receive the worst care of 36 developed nations. We cannot balance the budget by depriving patients care.

Ten percent of our $4.6 trillion spent on healthcare actually goes to physicians. If we are going to make any sense of healthcare spending at all, we would look at those two values and compare them. I have a feeling that CMS sucks up an incredible amount of money each year to do little except to create mischief for healthcare providers and patients.

Our healthcare budget management rests on the CMS model, that if we beat-up physicians enough, physicians will mend their evil ways, and everybody can live happily ever after. Belligerence is not the answer to decreasing the cost of healthcare. Indeed, nothing could be further from the truth. Most physicians don’t need to be beaten up to do a good job for their patients. Whatever time physicians need with patients to use their expertise to provide their patients the care they need should be reimbursed. Physicians shouldn't have to fill out a checklist of preventive care tasks to be paid for the time they spend caring for their patients. They should be paid for the actual time spent with patients even if there's nothing on the checklist—the real expertise of physician care never makes it into a chart.

Many years ago, most parents stopped beating their children as a method of establishing desired behavior. Today providers who are beaten up learn the same lesson children did 100 years ago. They tend to cover up the prohibited behavior. In the healthcare environment, we have layers and layers of hospital protocols and management that are designed to cover up mistakes in order to avoid draconian punishment.

Today physicians live in fear of being accused of imaginary sins. That fear only makes their ability to provide care more difficult and less effective. My best advice is to remove draconian punishment and to solve financial problems in financial ways, and to forget about threatening doctors in order to instill fear in the healthcare environment to reduce costs.

My understanding of value-based care is that payment to physicians should be based on some kind of vague or amorphous value. The main problem with trying to leverage the patient/physician relationship in order to control care is that physician payment is comprised of approximately 10 percent of the healthcare dollar. Since 90 percent of our taxpayer dollars go elsewhere than to physicians, we should really be looking at the other places these dollars are going:

• Hospital and clinic buildings and machines owned by private equity companies,

• CMS, including Medicaid, Medicare, and Medicare Advantage plans,

• Big Pharma,

• Insurance companies,

• Locums companies, (90 percent of locums costs reimbursed by federal government---meaning tax payers), and

• Large hospital corporations such as Medica and UnitedHealth.

After we have addressed the financial problems caused by these corporations, we can work on the much bigger and entirely separate problem of determining value. Although there are many physicians who are interested mainly in providing value to their patients, there are some who really don’t care. There’s nothing that CMS or anybody else can do to get physicians who don’t care to care. Adding fear of draconian punishment will not fix the problem of physicians who do not care. As Elizabeth Rosenthal says, only legislators can fix the problems with our dysfunctional healthcare system.

It would only take one stroke of a pen from legislators to turn off the syphoning of healthcare dollars away from patient care.