Shift toward value-based health care models not without problems

Nov 11, 2018

For some people, their yearly checkup is as easy as heading downstairs on their lunch break, as some companies are moving toward health care methods that put the physicians closer to the workers. That does not necessarily mean, though, that health care has improved at these companies, an author and health director said.

Carolyn Engelhard, director of the Health Policy Program in the Department of Public Health Sciences at the University of Virginia School of Medicine, co-authored the book “Health Care Half-Truths: Too many myths, not enough reality.”

Engelhard said these developing systems are signs of a shift from fee-for-service models of care toward more value-based care models. However, the results have not been consistently beneficial, oftentimes lowering the quality of care patients receive.

“There are inherent incentives in our health care system that push physicians to do too much, patients to want low-value care,” Engelhard said. “The trend is there, but how it manifests matters.”

"There are inherent incentives in our health care system that push physicians to do too much, patients to want low-value care."

One such model of value-based care is direct primary care, whereby primary care physicians cut themselves off from the medical system in regard to typical reimbursement methods. Instead, an employer contracts with primary care physicians for a monthly fee that allows for a certain number of visits and services per month (patients can also sign up on their own for direct primary care, if a provider is available in their area).

Because there is no physical relationship with an insurance company, this method helps to limit physician overhead. In addition, direct primary care reduces physician panel size, Engelhard said, which can severely limit who patients can see for high-quality care.

Another model is the direct contracting model, which builds through a pay-for-service model or a pre-payment system while being part of a bigger systems. This model involves relationships with specialists, putting the primary care clinic as part of the larger system at a worksite.

These approaches to health care are still relatively new, Engelhard said, and most of the evidence about how well they are working is anecdotal because physicians have become zealous.

“There’s nobody measuring quality outcomes,” Engelhard said. “I think it’s going backward in our health care system by sort of letting people be cowboys and cowgirls out there.”

"I fear that people will think of direct primary care as insurance and then be left kind of high and dry when they need that acute care or when they're diagnosed with something they don't anticipate."

One of the main problems Engelhard sees with newer systems like these is a lack of preventative care, mostly because it takes a while for people to see any results and they therefore do not see any point in investing in care that could save them much later in life.

“I fear that people will think of direct primary care as insurance and then be left kind of high and dry when they need that acute care or when they’re diagnosed with something they don’t anticipate,” Engelhard said.

To improve these direct-care systems, Engelhard said they need to be connected to a larger system. Unfortunately, she said, the systems that already do that, working off an insurance-reimbursement model, are not much better.

“Our reimbursement system today just does not appreciate primary care,” Engelhard said. “As a result, you get primary care docs that just have to churn patients through, and it’s very unsatisfying for both the physicians and the patients.”