Increasingly, the healthcare industry seems to be arriving at a consensus. Value-based, bundled and ACO care, it is believed, are keys to both improving quality and lowering healthcare costs. I'm here to tell you that I don't believe this to be true, and that in fact, some aspects of these models represent a return to the unfortunate aspects of capitated medicine. Just consider the following:
ASSUMPTION OF RISK: While I see little to object to in making doctors and hospitals accountable for the care they deliver, structuring payment as though all providers are capable of assuming financial risk for large bundles of care is foolhardy and unfair to the professionals involved. Simply put, providers should not be turned into insurance companies unless they're specifically choosing to do so.
PRESSURE TO UPCODE: While providers always have the incentive to code at the highest level they can justify, the pressure quadruples when a wrong choice of coding could mean big financial losses, not just a lower reimbursement level for their services. It doesn't make sense to put providers under that kind of pressure, as they've certainly got enough on their plate to handle right now, especially small practices wrangling with big business issues like ICD-10 and EMR adoption.
PUNISHMENT OF LAST-RESORT PROVIDERS: Yes, I know that in theory, bundled payment, value-based payment and the ACO model adjust for the acuity of patients a provider sees. But from what I've seen so far, none of these payment models go far enough to adjust for situations when a provider serves underprivileged population with poor health literacy and a multitude of chronic conditions. Do we really want to punish such providers by restricting further the resources they have to treat this population?
PRESSURE TO UNDERTREAT: Let's not kid ourselves—anytime a provider is working on a flat fee basis it imposes a temptation to undertreat or fail to refer for needed services. This is not to suggest that providers don't care about potential harm to patients, but rather, that they're trying to survive under a flat fee model. Yeah, doctors and hospitals get monitored to see if the pulling any stunts in this arena, and we may find that very few have done anything to limit care, but do we really want to give them a massive incentive to do so?
Bottom line, the truth is that we've already been to capitation's ups and downs in the 90s, and it just didn't work. The bells and whistles added to value-based payment and bundled services don't change the underlying fact that we're still basically dealing with a capitated model which has lots of warts. Disagree with me on this? Write me at [email protected]. I'd love to hear your views.
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