Where I Would Get Health Care If I Had Diabetes

An old friend who has adult-onset type 2 diabetes and has Medicare called me last week to catch up. We talk every few months and he shared with me that he was having a difficult time controlling his blood sugars. He has been seeing an endocrinologist who has prescribed long-acting insulin and my friend feels that perhaps his medication should be adjusted or changed. His reasoning was that he was experiencing significant unexplained weight gain and he felt just awful.
 
When he and his physician discussed his concerns, his physician told him, “You will need some time adjust to the medication.” To my friend this seemed like a feeble copout and even if it was true, he was unhappy with the level of care he was receiving.
 
The issue in this situation may indeed be the fact that my friend just needs to wait for the currently prescribed meds to take effect, but what if they don’t? He shared with me that he had lost faith in his doctor’s reasoning for his situation. He also shared with me that he was fortunate enough to get an appointment with a different endocrinologist who had good recommendations by several of his patients. But there was a catch—he could not get an appointment until January of 2023, a full 3 months from now.
 
Even if nothing overtly negative  happened to my friend’s heath, running chronically elevated blood sugars is the trigger to a lot of bad health conditions, and my friend already has the beginning of several of those conditions in his eyes and feet.
 
Our conversation eventually touched on the care of people with chronic diseases, like diabetes, and on the two business models used by physicians, fee-for-service and value-based care.
 
Value-based care vs. fee-for-service has been a choice for providers within the last 12 years. In 2010, the Affordable Care Act (ACA) codified reimbursement for value, or quality, instead of fee-for-service, or quantity, of care.¹

Fee for service is the traditional payment model for healthcare services in the United States. This structure allows for providers and physicians to receive payment from insurance companies, government agencies, other third-party providers, and individuals based on what services they offer to a patient seeking care. It also applies to the number of procedures that a provider might order. Payments are unbundled in the fee for service process, which means each item is billed and paid separately. That means every time a patient comes in for a doctor’s appointment, a consultation, or a hospital admission, the provider will bill for every item independently.² There appears to be a general consensus that Fee-for-Service (FFS) payment leads to overprovision, inefficiency and uncontrollable health expenditures.³

Health care organizations (are) under pressure from the government and private payers to demonstrate value (improve clinical outcomes and patient experience) while controlling costs.⁴ This is why the value care model has been promoted.

Simply put, the Value-Based Care Model rewards healthcare providers who focus on the quality of provided care. Reimbursement of services is based on those providers’ effectiveness in preventing illness and promoting health. Value-based care programs promote better healthcare for individuals, healthier lives for communities, and lower costs over time. Value-based care is focused on providing care that is effective, applied judiciously and documented accurately. Advocates of value-based care vs. fee-for-service say it improves patients’ health and reduces healthcare costs.¹ 

My friend’s endocrinologist, like many physicians in private practice, was working under the fee-for-service model, so his income was generated based on the number and types of services billed.
 
I explained to my friend that the fee for service model by nature waits for people to get sick and then treats their problem. They treat pathology. Prevention is not emphasized as it is contrary to the business model.
 
Value-based programs focus on the quality of care as opposed to quantity. The two models are completely opposite and the decision on which model to practice dictates how the doctor gets paid.
 
I suggested to my friend that he research integrated health companies in his area who use the value-based care business model and consider joining one of them. My reasoning was that Integrative Health is an individualized, client-centered model of promoting optimal health and wellness, combining a whole person approach with evidence-based strategies to reduce disease risk by turning around lifestyle behaviors.⁵
 
The obvious reason for my recommendation was that since my friend had a chronic disease, his health could be better managed by prevention, and a value care–based organization could be the best place for him to receive his health care.
 
People with chronic diseases don’t have the luxury of time to wait for proper care. So, I shared with my friend that if I had diabetes, l’d get my health care from an Integrated Health Care Company that embraces the value care business model.

Dr. Hinkes is President and Chief Medical Officer of ePrevenir, Inc. He is board certified by the American Board of Foot and Ankle Surgery and is a Fellow of the American College of Foot and Ankle Surgeons and the American Professional Wound Care Association. He is the author of “Healthy Feet for People With Diabetes” and “Keep the Legs You Stand On,” available at www.amazon.com.

References
 
1. Gebauer D. Value-based care vs. fee-for-service: what is the difference? Medical Advantage. Published Aug. 9, 2022.

2. Gaille L. 17 fee for service pros and cons. Vittana. Published April 20, 2019.

3. World Health Organization (WHO). Health System Financing. Geneva: WHO; 2010. p. 72-5.

4. Zhu J, Park C, Gupta L, Mukherjee D. New payment models in medtech. Deloitte Insights.

5. Jordan M. What is integrative health? A new paradigm for healing. California Institute of Integral Studies. Published Jan. 1, 2016.

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