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Barriers to Value-Based Care in Physician Practices

by | May 18, 2018

Real World Perspective from a Practice Transformation Coach

If you are working in the health care industry, outside of providing direct patient care, it is easy to believe that we are in the thick of value-based reimbursement. You hear about the concept everywhere, including blogs, websites, email newsletters, and conference presentations. A Google search of the term yields over two million results. From the outside looking in, value-based reimbursement appears to be the main focus of today’s health care delivery system.

But if you are on the inside looking out, providing hands-on care to patients every day, then value-based care may seem like more of a “blip” on the radar than a fundamental shift in the way health care services are delivered. As a practice transformation coach, I work with physician practices every day. Health plans need to understand the reality of physician practices if they want to succeed in implementing value-based care. Here are a few things I have learned through my experience in the field.

Value-Based Theory, Fee-Based Reality

Caring for patients in a value-based reimbursement model looks very different than caring for patients in a fee-based reimbursement model. Value-based care prioritizes engaging in proactive behavior today, in order to prevent problems tomorrow. This includes activities like care management for high-risk patients, closing gaps in care, and limiting patient panels to allow providers to dedicate adequate time and resources to each patient. While most physician practices can agree that these are valuable activities, they will also tell you that these activities are not feasible under the current fee-based reimbursement model.

Proactive care management activities yield little or no revenue to pay for the staff members performing these duties. The only activities that create significant revenue for the practice are face-to-face, billable office visits. While value-based care offers the potential for increased reimbursement in the future, most physician practices are consumed by the day-to-day reality of trying to serve as many patients as possible today, in order pay their bills tomorrow. It is hard on any given day to start directing resources away from patient care to build the necessary infrastructure for value-based programs.

When prioritizing between actual reimbursements now versus theoretical reimbursements at a later date, actual reimbursements will almost always win. This is not because providers are greedy, or even short-sighted. It is because the reimbursement for health care services has not increased to match the cost of inflation. The low reimbursement levels and increased pressure to see as many patients as possible can lead to reactive care patterns. The focus of care changes from what is the best care for each patient to what is the best care that we can provide for this patient in the next 15 minutes.

The health care system has operated under these limitations for so long that reactive care patterns are deeply ingrained in practice culture. Reimbursement models are a major challenge that health plans and other payers need to address in order to change physician behavior.

Time and Resources are Limited

If there is a topic that gets almost as much attention as value-based care, it is provider burn-out. This is probably not a coincidence, since the work of value-based care transformation must occur within the demands of the current fee-based system. The most common complaint I hear from practices when talking about transformation work is “We don’t have time for that!”

For someone who has never worked in a physician practice, it might be easy to shrug off this explanation as an excuse. But the reality of providing patient care on a daily basis paints a convincing picture. For every reimbursable moment spent face-to-face with a patient, there is a long list of tasks that must be completed in order to make that visit meaningful and profitable, including:

  • Entering demographic data
  • Verifying insurance information and eligibility
  • Record review and preparation
  • Ordering of referrals, tests, procedures, and prescriptions
  • Following up on any orders, as needed, in the days after the appointment
  • Communicating results and instructions to patients via phone or the patient portal

All of these tasks, and many more, are squeezed into the moments between patient encounters. Assuming that a typical practice sees a patient every 15 minutes, for seven hours per day, the practice staff will have to complete pre- and post-work for 28 patients per day, per provider. This doesn’t even account for patients who call the practice with questions, problems, and prescription refill requests outside of an office visit. Practice staff are running, from open to close, to keep up with the small but time-consuming tasks involved in patient care.

So, when is a practice expected to squeeze in the hard work of implementing value-based care transformation? In my experience, there is no easy answer. Transformation requires time for collaboration and energy for idea development and execution. If time is the most difficult commodity to find in a thriving practice, then energy is the second most precious resource. Caring for other humans, especially those who are ill and scared, is exhausting work. Expecting providers and staff to come in early, stay late, or give up their lunch breaks seems like the only option for many practices.

Imposing additional demands on overworked team members is a risk, especially when practices struggle to understand why the extra work is necessary in the first place. Health plans and payers have not always been successful in explaining or justifying the need for value-based care to physician practices.

Practices Don’t See the Value in Value-Based Care

I have never heard a practice say, “What we really need around here is a list of metrics that measures the quality of care we give to our patients so that we know we’re doing it right!” Providers and practice staff are confident they are delivering value to their patients, even if they are the first to admit that they could improve. At the end of each day, it is the direct feedback from patients that means the most to them, not their performance rate on colonoscopy screenings or the number of patients that have communicated with the practice via the electronic health record (EHR) portal.

The metrics used in value-based care contracts are imposed on physician practices by health plans and other payers who are looking to manage costs.

While quality and patient experience are also important, ultimately physician practices understand that the bottom line is what matters most in value-based care. Controlling the costs of health care in our country is everyone’s concern. However, the physician practice’s first, and often all-consuming, priority is to meet the needs of the individual patients sitting in front of them each day.

Most health care providers chose their profession based on their desire to help people, not because they want to track data and maximize efficiency. This works out nicely, because patients want to be treated as individuals, not numerators on a quality measure. When working with physician practices, it is important for health plans and other payers to understand their underlying beliefs and motivations.

Engaging Physician Practices in a Value-Based World

So, how do we help physician practices to manage the transition from caring for individual patients in a fee-based health care system to caring for populations in a value-based health care system? The first step is to acknowledge that physician practices may not be as invested as health plans and other payers in this new world of value-based care. In order to engage physician practices, we need to first acknowledge the reality that they face on a daily basis. Next, we need to meet them where they are at today, with resources and support that make the transition as easy as possible.

Physician practices are passionate about what they do. And they want to provide the best care for their patients. Whenever I work with a new practice, I always start with that goal in mind.


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