This month, we have a letter by Lili Brillstein, MPH, that describes the benefits of value-based health care and highlights potential issues with an earlier article by Dr Bobby Buka that favored fee-for-service health care delivery1 (page 8). We also bring you Dr Buka’s response. It’s a lively debate.
I think both of them are right in at least some ways. Both systems have their advantages. Both systems—all systems, I think—have their disadvantages, too. The problem with all these systems is that they have to contend with us human beings, with all our tendencies for both good and, well, not so good.
Fee-for-service incentivizes physicians to provide services. Ms Brillstein is correct, to a degree, that such a system rewards quantity. But our desire to do good for our patients and to protect our reputations incentivize quality to some extent as well. Ms Brillstein thinks we would be better off with a value-based system that incentivizes quality of care.
Dr Buka feels the problem with value-based care is that it is not centered enough on individual patients’ needs. However, value-based care could be designed to use measures that are quite specific for individual patient’s outcomes (eg, by assessing patients’ perceptions of success as an outcome). But gaming such a system is easily possible, too. By selecting to care for people who tend to be satisfied with their care and avoiding patients who tend to be dissatisfied, we could appear to be providing higher quality care even when we aren’t. The success of a value-based system, just like fee-for-service, will depend on our professionalism, our commitment to our patients, and our ability to suppress the baser elements of our human nature.
The propensity for incentives to work, sometimes in undesirable ways, was evident in the effects of managed care systems that were designed, ostensibly, to promote keeping patients well. When Dr Alan Fleischer and I investigated the effects of different health care delivery systems on how much time doctors spent with their patients, we found that being in a managed care system was one the strongest factors associated with how much time doctors spent with patients.2 But being in a managed care system was not associated with longer times with the doctor (as you might expect if doctors were doing more to try to keep patients well); having managed care insurance was a strong predictor of having less time with the doctor, which would be what a cynic may have predicted (that paying doctors a set fee would incentivize them not to take care of the patient).
Despite the limitations of the incentives in all these systems, day in and day out we give patients great care. We are (largely) committed to doing our best, regardless of how the system is set up. That’s why I’m optimistic, no matter what approach dominates the delivery of health care. Part of our commitment is to keeping up our skills, and one way to do that would be to take advantage of conferences such as the Interdisciplinary Autoimmune Summit (July 10-12, 2020). The interaction with other specialties is an excellent way to augment our skills for caring for our patients. You can read about a number of upcoming conferences for skill development and CME on page 12.
References
1. Buka B. Is value-based care really a solution for dermatologists? The Dermatologist. 2020;28(5):30-32. Accessed July 6, 2020. https://www.the-dermatologist.com/article/value-based-care-really-solution-dermatologists
2. Balkrishnan R, Hall MA, Mehrabi D, Chen GJ, Feldman SR, Fleischer AB Jr. Capitation payment, length of visit, and preventive services: evidence from a national sample of outpatient physicians. Am J Manag Care. 2002;8(4):332-340.
Disclosure: Interdisciplinary Autoimmune Summit is an educational conference by HMP Global, the publisher of The Dermatologist.
