Studies have shown that value-based care and value-based reimbursements are becoming increasingly effective at keeping communities healthier than traditional fee-for-service models. Therefore, it is imperative that we do everything we can to prevent alternative payment models from inadvertently deterring physicians from caring for those who are poor and vulnerable – the very communities they set out to help.
Value-based reimbursement models were designed to reward physicians who provide coordinated, quality care in a cost-effective manner; and consequently, penalize those who do not. These same studies show the positive impact value-based programs have already had – steadily improving clinical quality and care coordination while reducing readmission rates.
But for all the improvements we’ve already witnessed, we must understand that these current models account for only 20 percent of the healthcare factors that our physicians can manage. According to the Institute for Clinical Systems Improvement, healthcare – to include access and quality of care delivery – accounts for a mere 20 percent of a person’s overall health. Socioeconomic factors, physical environment, and health behaviors such as diet, tobacco and alcohol use account for the remaining 80 percent.
What this tells us is that where our patients live, work, play and pray have much more to do with their overall health. Although health is restored in a physician’s office, it is created in a community and culture where social, economic and environmental factors as well as human behaviors can shape a community’s “health landscape” – and ultimately, a community’s health outcomes. We need to make sure we create a reimbursement model that encourages physicians to think more broadly about these other health factors while not penalizing them for determinants beyond their control.
Karen Maddox, MD, MPH, said it this way in a recent New England Journal of Medicine article:
“Research has shown that care for people dually enrolled in Medicare and Medicaid costs more than care for people who are not, even after coexisting conditions are accounted for, probably because of such factors as functional status and social support that are not included in current risk-adjustment models. As a result, hospitals or clinics with a high proportion of poor patients may lose money under APMs [alternative payment models] through no fault of their own.”
No matter how well a physician delivers care, a cancer patient who works two jobs and cannot make it to his appointments is at an unfair disadvantage for a healthy outcome. A heart failure patient who must choose between keeping the lights on and paying for medication is at an unfair disadvantage for a healthy outcome. A diabetic patient who lives in a food desert is at an unfair disadvantage for a healthy outcome.
Consequently, our physicians are currently at an unfair disadvantage to treat people and communities negatively affected by these social determinants. Our physicians are asked to improve outcomes while managing only 20 percent of a given condition – conditions often compounded by co-morbidities that impact the vulnerable populations we serve.
This is an especially important topic for Ascension, the largest faith-based, non-profit healthcare system in the country, with a Mission to care for all – especially those who are poor and vulnerable. Nearly 64 percent of our patients rely on government-sponsored health plans. To address social determinants, we set a bold goal of eliminating preventable disparities in healthcare outcomes by 2022. Part of achieving that goal will require our physicians to be appropriately rewarded for keeping the communities we serve healthy.
I urge third-party payers and policymakers to design payment methodologies that factor in social determinants of health in addition to quality care coordination. This will become even more crucial as physicians are increasingly incentivized (or penalized) for their performance in the coming years. Our physicians deserve to be reimbursed for the compassionate care they provide – regardless of their patients’ gender, skin color, age, or the amount of money in their pockets.
Anthony R. Tersigni, EdD, FACHE, is President and CEO of St. Louis-based Ascension, the nation’s largest nonprofit health system.