Title : Value-Based Healthcare

Subtitle: Who is the Affiliated Beneficiary?

The nomenclature in the delivery of healthcare to the public-at-large has changed a great deal in the last 40 years. We had HMOs come into existence and became the gate keepers of access to healthcare rationing, which did not drive healthcare down in price but drove costs up. Key factors like preventive measures were not put into effect. 

Medicare and Medicaid stepped in and put a cap on medical procedures, and the price setting via IDC coding as major insurance carriers increased their profits. These factors became disruptive forces making American medicine and its public look forward to change regarding the insured and the uninsured population of America.  How was America going to adjust to these changes?

Ten years ago, the Affordable Care Act (ACA) came into existence to add more insurance to a large percentage of the American populous that did not have insurance or understood it. But more, the ACA did put in some of the progressive preventive elements that have become more accepting across the entire insurance platform today.  These preventive measures How to change the conversation and helping the transformation of a fee-based service to an incentive pay service. 

Let us first look at some of the nomenclature from the past, and we might be able to forge an understanding into the future. There is no doubt that disease-based or disease management was the epicenter of how we treated patients 40 years ago. We have now moved to a value-based healthcare system which will be explained below. Another piece of the revolution was the fact that hospitalization became an intermediary step which drove down the need for hospital beds which is falling by 30% since 1975.

Diagnostics were the critical tools used to diagnose disease states, but have now been moved to create a preventive format for early recognition in a disease state to get better outcomes. The past diagnostic equation was dependent on sickness, on disease, and on infirmary. On the preventive side, wellness and health maintenance were the tools that would come into use with new diagnostics, i.e., colonoscopies, gym memberships, even excise ware, i.e. running shoes and hiking boots.

Every doctor regards his/her population in the past as his/her patient population. However, the new nomenclature calls the group that seeks medical wellness, affiliated beneficiaries. Now this might be hard to swallow for most physicians because the doctor had as a patient load with a number of patients that they were responsible for. This was often because it was a fee-based service that would extrapolate into a known revenue stream for the physician. This is better known as a fee-for-service model. However, what has changed along with the name defining a new name for patients and how the physician gets paid. This mechanism is called incentive pay based on quality not quantity and outcome.

Let us define incentive pay: Incentive pay is a financial or non-monetary reward offered to employees for performance rather than the total number of hours worked or patients seen. Quality over quantity. Incentive pay is used as a motivational tool to boost morale and ensure employees perform at their best for better patient outcomes. Rewards can be offered individually or as part of a structured performance metric. This will put the negative drag of direct costs, medical errors and disease classifications under direct scrutiny.  This puts quality assurance in the front seat to manage risk, making it about your value based-care model.

Access to healthcare has certainly increased, and with the recent pandemic, telemedicine/video health has become a major staple in the way that people access healthcare without the commute to the doctor’s office, hospital or the urgent care facility.

If we can get to a model where we have more preventive care and less disease care, this creates increase in value for the Affiliated Beneficiary. This is where we are working on wellness versus medical disease management. This will lead to change in a better sense of compliance and cost cutting. What we have to do now is find what the Independent Physicians Association (IPAs) limitations are and what the problems are that we need to solve in this ever evolving model.

Treating the numbers of people in the healthcare field is probably one of the biggest problems facing us with the advent of a two-year coronavirus pandemic. The Primary Care physician shortage has been a chronic problem in America since most physicians want to be specialists. And now, almost two years after the COVID-19 pandemic began, the challenge has taken on new urgency. Primary care is grappling with an acute workforce shortage, where not only clinicians, but also support staff, are in short supply, some of it do to mental burnout.

With applicant pools shrinking and burnout at an all-time high, how can independent primary care physicians keep their practices running at full tilt? I talked about some of these technological advances that have and will assist in this deluge like Video Health/Telehealth. In today’s competitive job market, where work-from-home positions are on the rise, applicants are looking beyond base salaries to a job’s holistic benefits package. 

Mind you, some of this has to do with the fact that when I went to medical school many years ago, only 4% of medical students were women; today 53.7% of medical students are women. Women oftentimes have a dual task professionally and domestically. The domestic situation of raising a family oftentimes directs where that person will work from. Many primary care practices have found offering flexible work arrangements to be an effective strategy for both recruitment and retention.

Yes, medicine and medical nomenclature has changed a great deal in technology, gender demographics and medical discovery since my entry into medicine. We will come to understand that the “affiliated beneficiary” will always be the patient in the foreseeable future. And yes,Telehealth is still the patient seeing the doctor, but now with it’s coupled with digital technology…and maybe your doctor will be a woman!

Authored by Eric I. Mitchell MD ACPE

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