In a recently published article, authors argued that the current metrics used for value-based reimbursement in health care are insufficient and that only improved health outcomes can truly measure clinical value.
According to data from past studies, US health care spending has grown from only 6% of the gross domestic product in 1965 to now more than 18% of the gross domestic product. Despite this, the United States has consistently ranked lower than other industrialized nations in health care efficacy, equity, and outcomes, necessitating a change in the care delivery system. As a result, there is an increasing shifts away from a fee-for-services payment model, in which a patient or third party pays for any test or treatment, and towards reimbursement that is based on the value of the services being delivered by health care providers. In the early 2000s, the pay-for-performance plan was developed to provide incentives for improvements in quality and efficacy measures. But the problem is that some consider the metrics used to evaluate performance to be weak and not reflective of health outcomes.
In an opinion article published in the American Journal of Roentgenology, authors, led by Dipti Gupta, MD, Northwestern University, Evanston, IL expressed their concerns about value-based reimbursement models as they relate to physician autonomy. To define autonomy, the authors stated that it is, “the physician’s discretion—without external pressure—to use his or her best medical judgment to make management decisions.” Concerns about medical practice and the development of new evidence-based guidelines have decreased the degree to which physicians can act autonomously. However Dr Gupta and her coauthors continue that autonomy is not a license for physicians to act arbitrarily but rather an opportunity to best serve a patient’s needs in rapidly changing clinical environments.
While the authors acknowledge that switching from a payment model based on volume to one based on value holds immense promise for improving the quality of health care, they suggest it is also increasingly important to understand what value means, especially in the context of different stakeholders: patients, physicians, administrators, and payers (private and public). Value is an easy concept to endorse, but it can become more nuanced in the context of value-based reimbursement.
The contentious relationship between the autonomy of physicians and value-based models lies in the subjectivity of outcomes. Guidelines for breast cancer detection for women aged 40–50 years is just one example: one must balance the potential benefit of early detection of cancer with the risk of false-positive readings which can produce high costs, anxiety, and lead to unneeded tests. Therefore, the authors stated that, while measuring outcomes is important, these outcomes are not always binary. This is where physician autonomy must play an important role.
“The true measure of a physician’s value in medicine is the accomplishment of better health outcomes, which, in breast imaging, are best achieved with a physician–patient relationship. This relationship is one that requires a physician’s time and judgment—that is, physician autonomy,” authors concluded.
