Some Physicians Still Uncertain about Value-Based Reimbursement

Physician leaders must help their people understand the benefit of increasing their knowledge of the replacement payment model.

As health care delivery continues moving toward a value-based reimbursement model — bringing with it an alphabet soup of new acronyms and terminology — many physicians don’t yet know much about it.

Value-based care ties payments for delivery to the quality of care provided, rewarding providers for both efficiency and effectiveness. It has emerged as a likely replacement for traditional fee-for-service reimbursement. The transformation is supported by the Centers for Medicare & Medicaid Services, which has introduced numerous value-based care models, and insurance companies have adopted similar reimbursement arrangements.

David Muhlestein

It’s seen as an effort to advance the “Triple Aim” concept — improving patient experience, improving population health and reducing costs. But for patients, physicians and employers who provide insurance plans to their workers, cost is the top concern, according to a white paper released by Leavitt Partners in January 2018.

“What we focused on is different ways of paying. The majority of people aren’t sure yet,” says David Muhlestein, chief research officer at Leavitt Partners. The research showed between 34 and 58 percent of physicians surveyed were not sure about how value-based care would affect patient outcomes.

Some of that uncertainty might come from a lack of understanding about how the models work. Only 4 percent of the physicians surveyed said they had an in-depth knowledge of MACRA, the Medicare Access and CHIP Reauthorization Act, which became law in 2015. Thirteen percent had never heard of it.

“It’s not something you just pick up over a lunch meeting,” Muhlestein says. “When you’re a physician, you’re busy. You don’t really have the time to learn about payment reform. There really isn’t an incentive for them to learn about it.”

Eventually, that incentive might arise when a physician’s compensation falls because of noncompliance with new regulations, says Gary Josephson, MD, MBA, chief medical officer of Nemours Children’s Specialty Care in Jacksonville, Florida.

“I really believe in the why. When you understand the why, you are more likely to do the what and the how,” Josephson says. “I think it’s essential physicians understand what is going on.”

Once they understand, they are more likely to look for ideas of how to solve problems and do things better, Josephson says. “If I can engage them so they understand why changes need to be made, then they become engaged and help to make the change that’s necessary for us to continue to do our work successfully.”

The main question is how much to engage. “What is the role of the rank-and-file physician as we reform the health care system?” Muhlestein asks. “Is it a question of education? Maybe. Nobody says it would be bad for them to understand these payment models, but it is necessary? It’s a question about what is the best use of their time.”

Gary Josephson

That’s where the physician leader comes in.

“I think it’s very important that the physician leaders understand these issues,” he says, adding they also need to understand the disconnect doctors see between what happens behind the scenes and what directly impacts patient care. “They should educate the physicians on the front lines, but they need to do so at an appropriate level. Help them know what they need to know. That’s a very important role of physician leadership — finding what the sufficient level is.”

It’s something Josephson sees as his duty. “I think we have to educate. I think that’s part of our responsibility of physicians is education.” Josephson says he has given lectures and has sent written communications about the value-based models. “People communicate and learn in different venues,” he says, adding he also understands the time constraints on his fellow physicians.

But he can’t force anything on them. “I can’t force someone to learn, to come to a meeting. It’s not my leadership style. At some point and in some way, they want answers.”

That point may be what one leader calls the point of being consciously incompetent, where physicians know what they don’t know.

“Here’s what doctors hate. A doctor’s role is to be highly competent. No doctor doesn’t want to feel like they’re not on top of his game,” says Quint Studer, a former health care leadership consultant and hospital executive. “Any time we make a change, we move them back to consciously incompetent, and they hate it.”

This drives them to find out information and learn. “I don’t think we’re sensitive to the process of change with physicians who just assume they are superhuman beings who are going to adapt better than anyone else. And they really aren’t in certain areas,” Studer says.

Quint Studer

So where is the sweet spot of knowledge?

“You need to know something, but you don’t need to know everything. It’s somewhere in between,” Muhlestein says.

He likens it to driving. When we put the car in gear and push down the pedal to give it gas, many of us don’t really understand what makes the car go, but it does. There are specialists who deeply understand cars and can explain every detail and fix it when something breaks. The driver needs to know enough to put gas in the car and perform regularly scheduled maintenance but does not need to know everything. Muhlestein says it’s the same with nonmedical information for physicians.

“The organizations need to make decisions about who needs to know what and how much,” Muhlestein says, adding some physician leaders he knows do not know enough about the complex systems to teach it to the physicians they lead. “Physician leaders have many responsibilities that don’t involve tracking changes in payment models.”

He suggests staying up-to-date with health care policy and making a commitment to learning over time.

“It’s not enough to just cram for it, you need to have the context that comes with time,” Muhlstein says. “It’s like anything, you don’t master it overnight.”

Josephson has some advice for his fellow physician leaders.

“Don’t be frustrated. I get it,” adding there are always scheduling issues and overwhelmed physicians. “At some point and in some way, they want answers.”

AAPL senior editor Rick Mayer contributed to this report.

Tiffani Sherman is a freelance writer based in Florida.