Coronavirus disease (COVID-19) has left dermatologists with a lot of spare time for reflection. In some ways, the crisis serves as a pressure-cooker for innovation. It challenges providers to be prospective, to think about what new ideas or systems might empower us to provide better care to our patients—and which would be better left unexplored.
For myself, I have been thinking a lot about the role that value-based care should or should not have in dermatology.
Value-based care is a reimbursement structure that ties payment to objective care parameters.1 Typically, physicians in a value-based care system will receive a single lump sum to cover the entirety of a patient’s care, regardless of how long a given problem takes to solve or which services are necessary for treatment. This structure is meant to incentivize quality care and make sure that patients are taken care of quickly and effectively, rather than billing them fee-for-service if they seek care for the same problem multiple times.
Some dermatologists have held up value-based care as a necessary game-changer for the field.
“By relying on collected historical data and prioritizing quality of care over quantity of care, a value-based approach to dermatology cuts down on check-ups and incentivizes more effective medical solutions,” wrote Dr Robert M. Colton, chairman of the Florida-based network ClearlyDerm and proponent of value-based care.2 Dr Colton’s perspective is that a transition to value-based care would cut down on unnecessary visits and prioritize solutions that had an immediate impact on a patient’s health. His perspective echoes the limited-care mandates we hear in light of COVID-19: to treat as much as we can with as little patient contact as possible. While these limitations may be sensible during a pandemic, their impact during ordinary times would be disastrous for our specialty.
In the above-mentioned article, Dr Colton implies that dermatologists who choose one-and-done treatments are more “effective” than those who apply solutions that require multiple office visits because the problem is resolved more quickly. This logic is somewhat flawed; by making speed their priority, value-based proponents are also incentivizing aggressivity over all else.
Take a simple wart as an example. In a fee-for-service system, dermatologists can use a patient’s situation and preferences to determine whether freezing, electrocautery, or cutting would be the best mode of removal. Some patients may benefit from freezing the wart over several sessions, while others will benefit from undergoing a more invasive scalpel excision. The fee-for-service system gives dermatologists the flexibility to make the choice that is right for their patient.
But in a value-based system, dermatologists would be paid the same amount, regardless of how much time and effort they dedicate to a treatment. Given all else equal, I fear my fellow dermatologists would lean toward the “one-and-done” scalpel. The incentives that structure value-based care reimbursement could and likely would have a chilling effect on dermatologists’ willingness to apply gentler, long-term treatments.
Warts offer a relatively low-stakes example, but this thinking can be extrapolated to severe conclusions. Consider the case of a patient with atopic dermatitis. In a value-based system that ties immediate outcomes to pay, dermatologists may feel pressured to reach for a more expensive biologic that they know will work quickly rather than exploring gentler treatments that require less systemic involvement.
That said, value-based care is not just limiting from a care perspective, it is fundamentally flawed in its attempt to quantify “success” in dermatology as well.
In verticals such as emergency or primary care, there are clear metrics by which to measure success. Payers can readily gauge hospital readmission rates and judge whether an acute health problem—say, a cardiovascular event—was resolved within a reasonable time frame. This assessment makes provider efficiency and effectiveness relatively easy to judge and compensate by value-based standards.
It is worth noting that value-based care works for these specialties. In 2018, researchers for a UnitedHealthcare report found that organizations that used value-based models experienced a 17% drop in hospital admits and ranked 87% higher on top quality measures than comparable fee-for-service facilities.3 Similarly, another study published in JAMA found that participation in “one or more Medicare value-based reforms” led to a significant reduction in 30-day risk-standardized readmission rates.4 When clear metrics are readily available, value-based care works.
But in dermatology, that clarity is missing. There are no easy metrics to measure success or benchmarks to aim for; it’s difficult to define what a billable “success” looks like. If a dermatologist manages to reduce a patient’s acne manifestation from 30 pimples to 10, is that a success? Who’s counting these pimples? If a patient’s eczema covers just 40% of their body rather than 80%, or still covers 80% but at half the severity—are those changes enough to constitute an “effective” treatment? Some patients would say yes; others would leave the practice still dissatisfied.
Value-based care requires a clear metric of success to work as intended. Unfortunately, those precise measurements are difficult, if not impossible, to come by in dermatology. Even if I leverage all of my medical knowledge and dedicate my best efforts to address a patient’s condition, I still may not be able to solve a patient’s skin concerns entirely or within a short time frame.
Conditions such as rosacea differ from pneumonia. Dermatologic severity is often difficult to quantify and these diseases cannot be definitively “cured” within a few weeks. Moreover, there are myriad compliance and behavioral issues that can potentially affect outcomes, factors that physicians ought not be penalized for. If we were to start incentivizing along these lines, imagine the consequences. Would dermatologists begin choosing patients based upon their expected compliance?
Given the chronic and difficult-to-measure nature of most dermatologic conditions, force-fitting a value-based system that prioritizes quick fixes over thoughtful care would be problematic at best and downright harmful at worst. In our case, a fee-for-service system remains the best platform to compensate providers for their time and skills while ensuring that all patients can receive top-quality care.
During COVID-19, dermatologists may feel pressure to treat as much as they can with as little patient contact as possible. And while these measures may be prudent during a pandemic, they would have a chilling effect on the patient-doctor relationship in the long-term. As we consider potentially disruptive changes to our care model, we must remind ourselves of our duty to care, and stand firmly against a value-based care system. It will not offer the benefits it purports.
This is one revolution we can choose to forego.
Dr Buka is a board-certified dermatologist and is the chief executive officer and cofounder of The Dermatology Specialists, a full-service dermatology practice with locations all across New York City, NY. Dr Buka is a contributing founder of the First Aid Beauty skin care line. He is also the author of Buka’s Emergencies in Dermatology and the newly published Top 50 Dermatology Case Studies for Primary Care.
Disclosure: The author reports no relevant financial relationships.
References
1. LaPointe J. What is value-based care, what it means for providers? RevCycleIntelligence. June 7, 2016. Accessed May 1, 2020. https://revcycleintelligence.com/features/what-is-value-based-care-what-it-means-for-providers
2. Colton RM. A shift towards value-based care puts dermatology patients’ health front and center. Becker’s Hospital Review. April 2, 2017. Accessed May 1, 2020. https://www.beckershospitalreview.com/hospital-physician-relationships/a-shift-towards-value-based-care-puts-dermatology-patients-health-front-and-center.html
3. How Value-based Care is improving quality and health. UnitedHealthcare; February 2018. Accessed May 1, 2020. https://www.uhc.com/content/dam/uhcdotcom/en/ValueBasedCare/PDFs/Value-Based_Care_Report_SP_Web.4.11.18.pdf
4. Ryan AM, Krinsky S, Adler-Milstein J, Damberg CL, Maurer KA, Hollingsworth JM. Association between hospitals’ engagement in value-based reforms and readmission reduction in the hospital readmission reduction program. JAMA. 2017;177(6):862-868. doi:10.1001/jamainternmed.2017.0518
