Value-Based Healthcare Could Improve America’s Healthcare System


In the past, people had mixed feelings about the Affordable Care Act (ACA) and its provisions for low-income individuals. When President Trump took office, he promised to repeal the ACA. It is supposed to be replaced in the coming years with another health care mandate. However, medical experts are not sure what that mandate will include. Physicians and health care professionals hope that lawmakers will take the mistakes of the Affordable Care Act into account when they devise the new plan. It must be something that Americans of all income levels can afford, and it must be something that will not raise medical costs significantly.

Many Americans are uninformed about the current state of the Affordable Care Act (Also referred to as Obamacare) and where things are standing today. The individual mandate that required individuals to sign up for health insurance or face a tax penalty was repealed in December of 2017. This will take full effect at some point next year. Although this change was made, there is still a large number of people who are aware of what the future may hold. Patients and physicians alike, there is a lot of uncertainty in the air.

Why The ACA Is So Hard To Replace

Repealing and replacing the Affordable Care Act became a great platform for political candidates who wanted opponents of the healthcare mandate to vote for them. Although the idea sounds good to many people, replacing it is much harder than it may seem. One of the main reasons why it is so difficult is because reducing premiums means that costs must be controlled as well. Since cost control is one of the most complex parts of making health care laws, it will take time for legislators to fix the insurance mess. One side wants to mask the rising premiums with more subsidies, and the other side wants to prevent people with pre-existing conditions from buying insurance. These solutions lead to more government spending or decreased access to necessary care.

While the ACA included a few provisions that were supposed to lower health care costs, they were not guaranteed. They were merely experiments, and those experiments failed. Not very many politicians want to tackle the tangled web of healthcare costs today. However, they must address it to help Americans gain better access to health care. The ACA marketplace was complicated with continual insurance company withdrawals, and premium hikes. Its faults wound up hurting both patients and physicians. Its instability led to a much lower number of physicians who accepted ACA plans. The amount of participating American doctors in 2016 was only 57 percent, which was an overall decrease of over 60 percent in 2015. This finding came from a physician social medical network called SERMO.

Why Lawmakers Should Target Physician Approval

A thorough analysis of the ACA’s weaknesses is essential for healthcare to serve patients and physicians better in the future. One of the biggest failures of the Affordable Care Act was that it did not meet the needs of physicians. Since a large number of doctors did not want to deal with it, many Americans suffered as a result. Several of these individuals lost their family physicians that they had been seeing for years. If the new healthcare laws are more attractive to doctors, such a change may mean improved medical care and improved access for patients.

The overall problem for physicians is the lack of payment assurance. One of the main reasons why doctors did not want to accept ACA plans was because the plans had poor reimbursement structures. If the ACA would have stayed in effect and reimbursement levels would have been raised in the future, that solution alone could not have solved the entire set of problems. There were plenty of other issues with the ACA. Additionally, there were poor procedures for synchronizing out-of-network and in-network care. It was hard for doctors to work with maintenance organizations for health plans that were offered by the underdeveloped ACA marketplace. Some physicians were also wary because of the health insurance co-op solvency problems. If insurers that offered ACA plans failed, physicians did not receive their reimbursements.

What Happened When Physicians Refused Marketplace Coverage

When doctors did not accept ACA plans, it made the applicable laws less effective. However, care coordination suffered even more. For example, consider a scenario of a person who went to a hospital for a fracture. The individual had an ACA plan and needed a prompt surgery. Since the surgeons on duty did not accept the individual’s ACA plan, they did not know where to send the patient. The patient wound up suffering in pain longer because of the lack of coordination. In some other instances, waiting for proper care meant that a patient’s health condition worsened as well.

Making The ACA Replacement More Appealing

There are several ways for lawmakers to appeal to physicians and to health care plan participants. If they cannot find ways to guarantee reimbursements, they must develop some attractive incentives that will compel doctors and surgeons to participate more. Increasing reimbursements would be an easy choice. However, a market-sensitive plan would be a much better solution. Also, there should not be a sole focus on family doctors. There must be benefits for specialists as well. Tumors and serious injuries were treated as secondary problems under the ACA, and delayed treatment for such problems led to complications and steeper health care costs for patients. There must be better and faster coverage for such issues, and a vital component of that is making specialists easier to access. Lawmakers should also develop stronger risk-sharing agreements for special premiums.

Another suggestion is bundled care programs. Some hospitals are already using these types of programs, and they are offering procedure cost estimates for patients now. With a simple payment plan, patients know what to expect. Also, it is easier for family doctors and surgeons to get paid. Another benefit is that the set payment is often lower than what it would be if the hospital were to issue separate bills for individual services. If the patient’s estimate is low, the individual does not have to pay the extra costs. Alternately, if the estimate is high, the hospital simply keeps the extra money. Overall, the final cost is still less expensive for the patient. This program structure may lead to improved quality in both medical services and care coordination, and it may reduce costs for Medicare patients as well.

While the ACA was established for the purpose of helping patients, it was not optimal because of how physicians stopped accepting plans. If the future health care laws do not address the mistakes of the ACA, patients will be the ones who suffer the most. There are already delays in important services and treatments, and America’s lawmakers must uphold their commitment to protect the people they serve. By assuring physicians that they will be paid one way or another, they can take the first step toward that crucial change.

A Possible Solution: Value-based Health Care

Many notable surgeons and health care professionals are proponents of implementing a value-based health care bill. Value-based health care is a delivery model that pays providers based on the health outcomes of patients. Doctors receive rewards by helping patients become healthier and by reducing the prevalence of chronic diseases. This model uses evidence-based suggestions for health improvements.

Alternately, with the fee-for-service model, physicians are simply paid more when they provide a higher volume of services. Since the incentives are connected to providing more services rather than improving health status, this is not helpful for lowering medical costs or for helping Americans live fuller lives. With value-based services, the value that the term refers to is the outcome of a health service in relation to the cost of providing it. Lower medical costs and the health of patients are both top priorities with this system.

Potential Benefits of This System

There are several benefits associated with value-based health care delivery, and the advantages are not limited to patients. Doctors, insurers, payers, and suppliers also reap several benefits. Overall, these plans are better for society as a whole. Patients do not have to spend as much money to achieve better health.

They can manage chronic illnesses such as cancer, COPD, diabetes, high blood pressure, and obesity without spending a fortune. In a value-based system, a quicker recovery plan is the top priority for each patient. With fee-for-service models, it is more profitable to treat the symptoms of a problem rather than to treat the problem itself. The value-based system is better for patients since it promotes healing and prevention. They typically do not need as many procedures, tests and physician visits. Additionally, they may spend less money on long-term medications or treatments.

With a value-based system, one important benefit is that providers see greater efficiency and improved patient satisfaction rates. Although they may need to invest more time in providing services, they do not have to spend as much time managing chronic diseases. Patient engagement measures and quality measures may both improve if physicians focus on healing rather than on providing a higher volume of services. Also, providers do not face risky payment systems. This is true even with for-profit providers, and they actually stand to lose much less with a value-based model.

When risks are spread across a larger number of patients, the risks are reduced considerably. With a healthier population, there are fewer claims and fewer payouts. This means that payment pools are not exhausted as quickly. Payers can also improve their efficiency by using bundled payments that cover entire cycles. With chronic conditions, pay cycles can cover periods that exceed one year. In a value-based system, prices from suppliers are aligned with patient outcomes. Suppliers reap benefits with this setup since their services and products are connected to improved health status. Since nationwide prescription drug spending is increasing every year, this is a critical selling point for the model. There are several stakeholders in the healthcare industry who want manufacturers to connect price structures to patient outcomes, which is a process that will become easier as individualized therapies increase in popularity.

Another benefit of a value-based healthcare model is that society becomes healthier while overall spending decreases. When the amount of money that is spent to help people manage chronic conditions and cover expensive hospital stays decreases, the related gross domestic product percentage improves. Currently, medical expenditures make up about 18 percent of the GDP.

There are also new delivery models with value-based health care. These models completely transform the way physicians and their healthcare teams provide services. New models make a team-oriented approach a top priority. Also, data sharing is important for proper coordination and care plan management.

These new measures make it easier to determine the success of a model. One example is a medical home. With a value-based system, medical care is not in a silo. Specialty, acute and primary care procedures are all integrated in a special model that is called a patient-centered medical home. However, it is not an actual home. It is simply the name of an approach to patient services, and it is led by the primary doctor who oversees care for a patient and provides instruction to team members. PCMHs share medical records between providers for easier care coordination. Important information does not get lost or misinterpreted as easily this way. When one specialist can see test results and notes from another specialist or from a patient’s primary doctor, it is easier for that professional to develop a proper care plan. Also, sharing data may reduce the incidence of redundant tests or procedures. Extra tests and procedures only cost patients and health facilities more money.

Accountable Care Organization

Another value-based model example is an accountable care organization. An ACO is a product of the Centers for Medicare and Medicaid Services. It is designed to provide patients with high-quality medical services if they have Medicare. Physicians, hospitals and other healthcare team members provide care at a lower cost for each patient. With an ACO, each member of the team shares some degree of reward and risk. There are incentives for them to improve care access, quality and outcomes. Also, there are rewards for reducing costs. In fee-for-service health care, providers have reasons to order more tests and procedures. They are rewarded with more pay by making patients pay more. Also, using expensive testing equipment means higher maintenance costs for health facilities, and they ultimately pass those costs on to patients.

As it is with PCMHs, ACOs are dedicated to promoting health and not just treating symptoms. In ACOs, providers and patients are partners in making care decisions. Additionally, ACOs encourage coordination and sharing of data between team members. This helps them work toward their goals more efficiently. Clinical data and claims data can be shared with payers, and this demonstrates better policies for improved outcomes. Adverse outcomes that facilities try to reduce include poor patient engagement, decreased population health and hospital readmission.

Hospital value-based purchasing is another model example. With VBPs, hospitals that provide acute care get adjusted payments. The payments are based on the quality of delivered care. VBP programs are meant to help hospitals improve acute inpatient care for everyone by eliminating or lowering the incidence of adverse events such as errors that cause harm to patients. Also, they use standards that are backed by evidence and research to yield better outcomes. With VBPs, hospital processes are also changed to create better experiences for patients while they stay. VBPs give recognition to hospitals that provide quality care for less money, and they promote better transparency in care standards. In the near future, VBP measures are expected to improve. Since hospitals will be able to boost their reimbursements and their reputations, they will likely seek VBPs in the coming years.

What The Future Holds For Health Care

Healthcare professionals who realize the importance of a value-based system are hopeful that this type of health care will grow in popularity. However, switching the system from a fee-for-service model to a value-based model will take time. The transition of priorities will create some problems, and the associated changes may be difficult to address. As healthcare continues its evolution, more providers will likely adopt the value-based care model.

Also, more providers are likely to adopt it when they realize the financial benefits. This big transition may be necessary if Americans want to see possible improvements in the healthcare system and if they want to see lower costs. Many surgeons and medical professionals hope that lawmakers will put the health and lives of Americans first when they develop solutions to change the ACA

Ultimately things are slowly changing, but we have a long way to go until America’s Healthcare system improves to the levels it needs to. There are dozens of ways in which this system could benefit the public. I am optimistic there are things to be discussed. As an Orthopaedic Surgeon, I can attest to the hope valued based health care could bring.