3 surgeons’ predictions about value-based care, including how curbing costs could deny patients access

Practice Management

Some spine surgeons say value-based care will grow with increased specialization of care delivery. Others argue value-based care poses conflicts for some patients and physicians.

Here are three surgeons’ predictions about the future of value-based care.

Note: Responses were edited for style.

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

Kern Singh, MD. Rush University Medical Center (Chicago): Lower back pain, most commonly arising from degenerative conditions, accounts for most years lived with disability worldwide, with direct annual costs in the United States for dealing with degenerative spinal pathology estimated to lie anywhere between $80 billion and $100 billion. As such, spine care is at the epicenter of the national trend to decrease healthcare costs, and providers of spine care are under increasing pressure to adapt to a value-based healthcare system.

Bundled payment models are increasingly being utilized by private and public payers to disincentivize unnecessary costs tied to a fee for service model. These payment paradigms, as they currently exist, are hampered by dependence on diagnoses-related groups that currently are not adjusted for procedure specific and geographic variation or individual conditions. The future of these payment models will likely incorporate input from surgeon experts to stratify bundled reimbursements by patient comorbidity burden, complexity of care, geographical variation and elective vs. nonelective conditions.

Additionally, the future of value-based spine care will see an increased specialization of care delivery. With increasing anesthetic capabilities and the shift toward minimally invasive approaches in spine care, an increasing segment of spine procedures that are reliable and less complex will be performed at ambulatory surgical centers whereas complex care will be carried out at centers of excellence at large multispeciality hospitals. This trend toward specialization will allow for increasing surgical volumes down each care path, leading to greater operational standardization and efficiency, improved patient outcomes and decreased costs.

Issada Thongtrangan, MD. Microspine (Scottsdale, Ariz.): The definition of value is quality over costs. "Quality care" in the surgeon’s perspective and patient’s perspective, and even insurance’s perspective, is very different.

Many surgeons look at "quality care" as the number of successful cases per year or successful fusion utilizing cutting-edge technologies, etc. However, the patients are looking at "quality care" as the quickest, fastest, safest, and most effective way that they can return to their “normal” with no pain, whereas the payers look at "quality care" as the cheapest care possible that they are willing to pay.

The spine community needs a common ground to define “value-based care."

Ironically, "value-based care" comes with a cost. It will be difficult for an independent practitioner like myself, as we do not have infrastructures or supportive systems like the bigger groups or hospitals. I have been collecting the outcomes of my patients to prepare for this in the future.

Thomas Schuler, MD. Virginia Spine Institute (Reston): The value-based care system is a model where there is a conflicting incentive for doctors and patients.

Under the value-based care model, healthy patients with less rate of complication will have access to care, and patients with comorbidities or higher complexity cases will not have the same access to care. 

Doctors within this model are strongly disincentivized to provide care if they operate on patients with comorbidities. If complications occur in patients with comorbidities, and they will occur, then the doctors providing care will be financially punished. Consequently, to avoid these losses, the value-based system leads to rationed care. Doctors outside this system will need to provide essential care to individuals who are denied access to care because of the perverse incentive system built into the value-based care model. We know of physicians that refuse to operate on patients because of these financial disincentives. 

The attempt to drive down healthcare costs will be achieved by denying access to healthcare to all. 

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