Dear Editor,
In his 2017 article, A Shift Towards Value-based Care Puts Dermatology Patients’ Health Front and Center, Dr Robert Colton discusses how a value-based health care model (VBCM) compensates physicians based on their effective treatment of their patients, not on how many times they treat them.1 In other words, effectiveness is measured by condition outcomes vs by individual treatments. This model is clearly distinct from the prevailing fee-for-service model, in which providers are paid for every increment of care delivered, regardless of outcome. That is not to suggest that doctors deliberately provide care that is not necessary; alternatively, the predominant payment methodology in the United States rewards for quantity of care rather than quality of care delivered and leaves no room for true accountability to the patient.
Unlike fee-for-service models, in which payors provide authorization for certain treatment, inherently embedding them in the process, VBCMs aim to shift the focus of payors to outcomes and leave the clinical decision-making in the hands of the providers. In the most effective VBCMs, outcome measures are mutually agreed upon by the partners: payors, providers, and others involved in the patients’ care. The measures can be short- or long-term, depending on the nature of the condition and clinical guidance of the physician partners. By leveraging the expertise of each individual stakeholder, these models have substantial runway for success. Clinicians, not just payors, are called upon to help define what is meaningful in terms of outcomes, which often means using a combination of payor and provider/clinical data to determine success.
In a recent article citing Dr Colton’s piece, Dr Buka contemplates VBCMs in dermatology.2 He errantly suggests that speed and aggressive treatment are the highest priorities in VBCM. This is a misunderstanding. VBCMs are designed to create accountability to the patient, reduce variation in care and cost of care among patients who are clinically similar, and optimize patient outcomes, experience, and use of resources. The goal of value-based care is not to get to the fastest treatments or most immediate outcomes; rather, it is to allow for consideration of all care a patient requires in order to get to the best outcome. The intent is to help physicians maintain (and in some cases, regain) clinical independence and compensate them for the outcome of the care they determine is best.
The fee-for-service model often leaves physicians and other care providers rushing to get through their appointments, as the basis of their revenue stream is volume. VBCMs, on the other hand, are designed to reduce inefficiencies and waste in care delivery and compensate providers based on results of the care delivered. This ultimately allows physicians more time to consider the comprehensive and complex nature of, and best treatment plans for, their individual patients, instead of performing as many treatments as they can, regardless of effectiveness, to be sure they get paid.
In Dr Buka’s example of treating atopic dermatitis, he suggests that a VBCM might incentivize or pressure a physician to reach for an expensive biologic that will work rapidly versus “gentler” options that have potentially less systemic involvement.2 He fears that because doctors will get paid the same regardless of time and effort invested, fellow dermatologists will “lean towards the ‘one-and-done’ scalpel”2 to quickly get to the outcome, regardless of whether that treatment option is best for the particular patient.
This is a grave misunderstanding of the concept of a VBCM. Value-based health care is not about “quick fixes.” In fact, it is fundamentally about taking a much longer and more comprehensive view of the patient, unlike the current fee-for-service system, which is focused strictly on increments of care delivery that occur in the immediate present without regard to their impact on the overall and longer term health of the patient.
That is not to say that Dr Buka gets it totally wrong. He is correct in saying that VBCMs require clear metrics and that it is not always easy to define those metrics from a claims perspective. Chronic conditions will require a combination of claims and clinical data, thus a collaborative partnership between payor and provider, with the goal of holding all parties accountable for an optimal patient outcome.
Metrics that Dr Buka cites, such as emergency room visits and hospital admissions, are typically used as standard outcomes measures across many, if not all, VBCMs. While these serve as a baseline, they are often analyzed in conjunction with episode-specific metrics (ie, metrics specific to the diagnosis, health care event, or procedure that is being managed and measured). Episode-specific criteria must be defined in collaboration with health care providers who have the clinical expertise to define what clinical success will look like for an individual patient. In the instance of a chronic condition, there may be intermediate metrics defined to manage and course-correct in close to real time, but that is again about getting to the best clinical outcomes and not about the immediacy of those outcomes.
VBCMs are not about prioritizing “quick fixes over thoughtful care.”2 They are designed to allow for more thoughtful care and to ensure that patients receive the best, most appropriate, and most effective treatment for their particular situation and that physicians are rewarded for achieving those outcomes.
Lili Brillstein, MPH
Ms Brillstein is founder and chief executive officer of BCollaborative in Pine Brook, NJ.
I have read with great interest Ms Brillstein’s Letter to the Editor and appreciate the time and attention given to raise certain objections to our coverage of VBCMs. She correctly opines that a VBCM is geared toward “reducing variation in care among patients who are clinically similar.” This is precisely where this model runs aground. As physicians, we are entrained to treat individuals, not conditions; as caregivers, we are reminded to treat people, not similar cases. How many occasions throughout medical school and residency have we been reminded to refer not to “psoriasis in room 4,” but “Mr Smith in room 4 who has psoriasis”? This means we deliver medicine that is backed by evidence, while our humanity insists that we approach each patient as an individual.
VBCMs push us toward vending machines of care, disallowing a provider’s breadth of experience and critical thinking. Our specialty has trained for too long and fought too hard to acquiesce to automatization. There is clear tension between Ms Brillstein’s suggestion that we reduce variation in care whilst also insisting that a VBCM allows “for consideration of all care a patient requires.” These comments are clearly conflated – how to consider all care for a patient when I am confined to reduced variation under VBCM? The proposition runs directly contrary to clinical independence.
Simply put, if a physician were offered $1 for every patient with acne cleared, regardless of treatment course, do we suppose a VBCM supports a “much longer and more comprehensive view of the patient”? Or will we observe an unfounded spike in isotretinoin prescriptions written?
Let’s move on to where we agree. Clear metrics in dermatology are exceptionally challenging to define and cumbersome to mobilize. Ms Brillstein acknowledges the real difficulty in measuring progress among our chronic conditions and offers the institution of even more “intermediate metrics designed to manage and course-correct.” I rue the day when I am asked to make a case to my payor-representative that I have achieved a subjective pruritus score of 2+ down from 3+, and may I please be reimbursed for my metric improvement?
We all want responsible autonomy for our profession. We are ethical, caring professionals who give our all for our patients. We endeavor to improve skin conditions as swiftly and safely as possible. Our current fee-for-service model provides payment for time and expertise rendered without devaluing our profession. n
Bobby Buka, MD, JD
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.
References
1. Colton RM. A shift towards value-based care puts dermatology patients’ health front and center. Becker’s Hospital Review. April 2, 2017. Accessed June 28, 2020. https://www.beckershospitalreview.com/hospital-physician-relationships/a-shift-towards-value-based-care-puts-dermatology-patients-health-front-and-center.html
2. Buka B. Is value-based care really a solution for dermatologists? The Dermatologist. 2020;28(5):30-32. Accessed June 28, 2020. https://www.the-dermatologist.com/article/value-based-care-really-solution-dermatologists
