How to succeed in value-based care without really trying

Craig-Joseph-1In 1952, Shepherd Mead wrote How to Succeed in Business Without Really Trying, a tongue-in-cheek “instruction manual” based on his experiences climbing the corporate ladder. Sample chapter titles included “Stab the Right Backs,” “The Look of Suffering,” and don’t forget “Be a Meeting-Leaver.” The book was soon turned into a Broadway musical and then a movie! While Mead actually did start his career in the mailroom, and really did rise to become a vice president at an advertising agency, his recommendations were helpful if a wise reader simply did the opposite. In this vein, I offer up some free (and remarkably cynical) advice to physicians and healthcare system leaders about how to succeed in value-based care (VBC) without really trying.

Before regaling you with the specific techniques for winning the VBC game, it is important to understand what value-based care even means. Until the last few decades, most physicians and hospitals were paid by insurance companies based on how many patients were seen and how sick they were. Doctors made more money by seeing more patients in their clinics. Similarly, hospitals were paid more if they provided more expensive and complicated services to their patients. Since we in the United States spend more per capita than any other nation in the world (no one is even close!), it makes sense to consider moving from volume-based care to value-based care.

In VBC, healthcare providers are financially incentivized based on outcomes-based metrics: Did you improve your patients’ health, reduce chronic disease, and enhance patient experience? If so, you get paid more. If not, well … you can figure out what happens then. Predictably, it can be quite tricky to translate “improve health” and “reduce chronic disease” into concrete numbers upon which everyone (payer and payee) can agree. The words “My patients are just sicker, so it’s not fair to compare me to those other doctors” may – or may not – have ever been uttered in VBC conversations.

So, what are some facetious formulas for “success” in value-based care? To begin with, ensure that everyone knows their place. Only physicians contribute to the health of their patients! There is no “MD” or “DO” in team; hence, team-based care is useless. Nurses, pharmacists, social workers, therapists, front-desk clerks? No, no, and no. The doctor is the beginning and the end of the patient-care story. What about the patients themselves? Aren’t they an essential part of the care team because they are, after all, the reason there is a care team in the first place? Absolutely not. Most of these “patients” never went to medical school, so how could they know what they want or need?

Another “successful” technique for VBC is to eschew technology. Instead, invest in paper: lots and lots of paper. I remember the good old days when if you wanted to know how your diabetic patients were doing, you hired a bunch of staff, asked them to track down results from various labs and your patients themselves, and then collated all the data. Was it accurate? No way. Timely? Ha! Were you able to look for population-based trends and act to improve the outcomes for large groups of patients? Umm, not exactly. But think of all the money we saved on electricity without all those fancy electronic health records (EHRs) and their fancy analytic tools. No thank you, I say.

Many think that clinical documentation improvement (CDI) programs will help a healthcare system thrive in the value-based care world. Well, I guess that depends on what you mean by thrive. Sure, helping physicians and nurses accurately and meaningfully note what they did and why they did it might be a good thing, given that unreasonable documentation requirements can lead to clinician burnout. And having the necessary data to measure how patients are doing with respect to chronic conditions and general preventative care is surely helpful. Still, wouldn’t it just be easier to write, “Patient doing ok with their problems” and quickly move on? Think of all the time that would save!

To really achieve “success” in value-based care, we should minimize the use of telehealth. Let’s be honest: We’ve spent a lot of money and resources on those fancy medical office buildings and hospitals. Some of them even have fountains, marble lobbies, and free Wi-Fi! Why wouldn’t patients want to experience all these luxuries? Telehealth gets in the way of all of that, so it must be bad. I acknowledge that there’s convenience for both the doctor and the patient. And telehealth can help healthcare scale by bridging insurmountable distances. Of course, telehealth can promote group visits, which also helps with the scaling problem. But what about the fountains?

Finally, it’s important to admit that to promote VBC “success,” we should ignore primary care and the entire concept of continuity of care. It’s so old-fashioned to promote the idea of a medical home for all patients, especially those with chronic diseases. What could be better than having a consistent team of clinicians, social workers, therapists, and insurance experts who understand the totality of the patient’s medical issues and social determinants of health and who work in a team-based way to not only deal with current concerns, but also to proactively anticipate future issues? The opposite, of course! We all enjoy repeating our life story to a new doctor every time we seek care. I know personally, as a patient, answering the same questions with every encounter keeps me on my toes. I appreciate that opportunity, and I’m confident that I’m not alone.

To be clear: Much like Mead’s original book, you would be wise to do the exact opposite of whatever I’ve recommended in this article! I must admit that I really am a fan of team-based care, technologies such as EHRs and sophisticated analytics, CDI, and telehealth. Heck, as a primary care pediatrician, I guess I’m even a supporter of primary care and the medical home. But you can’t fault a person for wanting to break into show business just like Mead did. The only problem now is who will play me in the movie? I’m thinking George Clooney. George, if you’re reading this, call me!

Topics: value-based care, featured

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