Who decides 'quality' in value-based care is still unclear: Dr. Vladimir Sinkov

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Value-based care has gained traction in spine and orthopedics, and some surgeons say it can hold physicians accountable and has the potential to be more effective. However, others, including Vladimir Sinkov, MD, say more definitive consensus is required in areas of value-based care.

Dr. Sinkov, of Sinkov Spine in Las Vegas, told Becker's why he's skeptical.

Note: This response was edited for style.

Question: What does the future of value-based care look like?

Dr. Vladimir Sinkov: Value-based care has been promoted for many years as an alternative to fee-for-service medical care. The motivation was to improve quality and reduce cost of medical care in the United States, the country with the highest healthcare spending per capita in the world. The basic premise of value-based care is that when healthcare providers who can bill for their services independently and get paid for each service provided, then they will inevitably be driven to provide more services in order to get paid more money. So they want to change that and stop paying physicians for the volume of work done, but instead pay them for the "quality" of their work. It is still not clear to me who gets to define the "quality." 

This premise, if you really think about it, is horrific. It basically implies that if left "unchecked," all those healthcare professionals that spent many years in training, sacrificed their personal lives, took oaths and are bound by legal and ethical standards of their licensing boards are simply out there to squeeze every dollar from the unsuspecting patient and their insurance company by providing as many medical services as possible regardless of how bad the quality is, what is medically indicated and what is in the best interest of the patient. The doctor-patient relationship, first and foremost, is built on trust — the doctor trusts that the patient is being honest with them about their symptoms and treatment goals and the patient trusts that the doctor will give them the best possible medical advice and/or offer treatments that are most beneficial for that patient. "Value-based" care proponents proclaim that doctors simply cannot be trusted and are only in this for the money. If this was true, then doctors should not and cannot exist as a profession.

Thankfully, most people realize that this is not true and that most doctors can be trusted and will do what is best for their patients. Yes there are few exceptions and "bad apples" that deviate from their professional standards and are motivated by money more than by their desire to help their patients. Such exceptions exist in every profession and there are already many laws and regulations in place to prevent or prosecute such offenses in healthcare.

Another problem with the concept of "value-based" care is that the definition of that "value" widely differs among the various entities in the healthcare system. For insurance companies, the greatest value is getting as much premiums in and paying out as little as possible in medical claims. For the hospitals, the value is getting as many elective surgeries done on patients with private insurances as possible while utilizing the cheapest implants. For the politicians it is creating healthcare policies that result in most votes and donations from lobbyists for re-election campaigns. These three entities are the major decision makers in today's U.S. healthcare system. The only value that should matter is the one that provides the maximum benefit to the patient. To my knowledge, none of the value-based healthcare efforts that I have seen to date prioritize maximum benefit for the patient as their main goal.
WIth that said, politicians, hospital systems and insurance companies will likely remain in control of the majority of the U.S. healthcare system and will continue implementing "value-based" care that will inevitably result in more regulations and higher costs (mostly due to increased demand for "middle people" to deal with the regulations) while providing lower quality care and less access to care to the patients.

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