Where Are We On The Road To Value-Based Care?

Change in health care is inevitable with the pending insolvency of the Medicare Hospital Insurance (HI) Trust Fund in 2026, absent congressional action.^1-3 The much-debated solution for over a decade is a shift from the fee-for-service (FFS) model to the value-based care (VBC) model. Nevertheless, fee-for-service remains the predominant payment model for podiatric physicians despite employment type. Although federal and private health care insurance plans attempt to push providers away from fee-for-service and towards value-based care, medicine remains a volume business.⁴ Moving towards improved outcomes while reducing costs, wasteful inefficiencies, and health disparities seem elusive but must be the goal.⁴

Value-based care remains a confusing topic for providers of all types, but in my observation, it seems arbitrary at best for specialists and fictional at worst. One unanswered question persists: Are podiatric physicians primary health care providers of the lower extremity or specialists? I believe the answer is both one of the unique features of podiatric medicine and surgery that make it not only an appealing career choice but well-positioned for the impending move towards value-based care.

Value-based care has many iterations, but the four basic Advanced Payment Models (APMs) are:⁵

1. Shared savings—"Generally calls for an organization to be paid using the traditional FFS model, but at the end of the year, total spending is compared with a target; if the organization's spending is below the target, it can share some of the difference as a bonus."

2. Bundles—"Instead of paying separately for hospital, physician, and other services, a payer bundles payment for services linked to a particular condition, reason for hospital stay, and period of time. An organization can keep the money it saves through reduced spending on some component(s) of care included in the bundle."

3. Shared risk—"In addition to sharing savings, if an organization spends more than the target, it must repay some of the difference as a penalty."

4. Global capitation—"An organization receives a per-person, per-month (PP/PM) payment intended to pay for all individuals' care, regardless of what services they use."

The most participated APM is arrangements without downside financial risk.⁴ Driving the shared risk model with a potentially higher reward has the highest potential to reduce costs while improving outcomes. Unfortunately, podiatry's participation in Accountable Care Organizations (ACOs) continues to be minimal, which is typical for most specialists. Meaningful participation in the value-based care model is daunting for solo and small podiatric practices, particularly higher-risk models.

The consolidation occurring in the podiatric market is an instrumental opportunity for the inclusion of podiatric physicians. An organization incorporating a strategic VBC plan requires forward-thinking leadership, infrastructure, appropriate resources, robust data analytics, ancillary services, and a holistic approach to lower extremity healthcare. Unfortunately, not all organizations can meet these demanding requirements to maximize the value-based care opportunities. Therefore, understanding a potential partner's capabilities of embracing value-based care as an earlier adopter with a data-driven strategic plan should be a top priority for all podiatric physicians, whether in the private practice, hospital-employed, or group-employed.

"The road to value-based care: Your mileage may vary. A report from the Deloitte Center for Health Solutions" stated:

"The pressure will likely only get stronger to shift toward more complex and financially risky payment models. Whether they decide to travel solo or with partners, health care organizations that leave now on their trip to VBC can put in place the necessary capabilities and processes that may give them first-mover advantage and increased market share, while others may be left behind."⁴

During this season of gratitude and thankfulness, I am grateful to be part of a team that recognizes the importance of value-based care and the unique opportunity it represents for podiatric physicians as both a lower extremity healthcare primary care provider and specialist. I feel that my practice organization is well-positioned to engage fully in the value-based care models to be part of the solution and positively disrupt healthcare.

Dr. DeHeer is the Residency Director of the St. Vincent Hospital Podiatry Program in Indianapolis. He is a Fellow of the American College of Foot and Ankle Surgeons, a Fellow of the American Society of Podiatric Surgeons, a Fellow of the American College of Foot and Ankle Pediatrics, a Fellow of the Royal College of Physicians and Surgeons of Glasgow, and a Diplomate of the American Board of Podiatric Surgery. Dr. DeHeer is a Partner with Upperline Health and the Medical Director of Upperline Health Indiana.

References

1. Jacobson G, Gustafsson L. Putting Medicare solvency projections into perspective. The Commonwealth Fund website. Available at: https://www.commonwealthfund.org/blog/2021/putting-medicare-solvency-projections-perspective . Published September 1, 2021. Accessed December 21, 2021.

2. Congressional Research Service. Medicare: insolvency projections. Available at: https://sgp.fas.org/crs/misc/RS20946.pdf . Updated October 25, 2021. Accessed December 21, 2021.

3. Frank RG, Neuman T. Addressing the risk of Medicare trust fund insolvency. JAMA Network. Available at: https://jamanetwork.com/journals/jama/fullarticle/2775457 . Published January 26, 2021. Accessed December 21, 2021.

4. Werner RM, Emanuel EJ, Pham HH, Navathe AS. The future of value-based payment: a roadmap to 2030. Available at: https://ldi.upenn.edu/our-work/research-updates/the-future-of-value-based-payment-a-road-map-to-2030/ . Published February 17, 2021. Accessed December 21, 2021.

5. Gerhardt W, Korenda L. The road to value based care. Your mileage may vary. Available at: https://www2.deloitte.com/us/en/insights/industry/life-sciences/value-based-care-market-shift.html . Published March 20, 2015. Accessed December 21, 2021.