“Make no mistake, we will be measured against our peers, which is why if you don’t accurately describe that patient’s comorbidity risk, you are under-coding the RAF score of your patient,” he continued. In such a scenario, “your cost benchmarks become out of balance to the reality of the patient’s condition that attributes to the final cost of care.”
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November 2024As for other steps the otolaryngology profession must take, “Right now, as noted, we are firmly a category 2 specialty,” Dr. Harrill said. “So, what documentation and billing infrastructure do we need to progress beyond that? What partnerships do we need to forge? If we address just that alone in the next five years, our profession will be in a very strong position when some of these currently voluntary VBC programs become mandatory.”
In that scenario, “we’ll have the data transparency systems and otolaryngology-developed clinical measures in place to become high-performing VBC physicians.”
Patients, Payers, and Burnout
George A. Scangas, MD, an assistant professor of otolaryngology–head and neck surgery at Massachusetts Eye and Ear at Harvard Medical School in Boston, stressed that although VBC discussions often focus on complex cost/value equations, “at the core of VBC is a focus on person-centered, coordinated care. Often physicians hear from patients with complex or undiagnosed medical conditions how they wish their providers would communicate more freely across medical organizations. And they are right.”
Otolaryngologists, Dr. Scangas continued, “often treat complex medical conditions that require interdisciplinary collaboration for optimal outcomes. This requires deliberate, time-consuming, and non-reimbursable efforts. A system that rewards such collaboration should benefit individual patients and, hopefully, also decrease physician burnout rates.”
The value expression for specialty care will [be driven by] the specialists defining the limits of what their expertise can do.” — Frank Opelka, MD
“Bringing focus to preventing burnout during the transition period will be critical in the intelligent design of VBC programs.”
Frank Opelka, MD, the immediate past medical director for quality and health policy at the American College of Surgeons, offered a caveat when trying to define VBC. “Value-based healthcare means something different to every stakeholder,” Dr. Opelka said. “No matter who you ask, almost no one has it right. They just have FFS with tacked-on measures that are tied to a transaction. It is not value until the individual seeking care knows how and where to find the care that meets their goals and that is safe, affordable, and equitable.”
Dr. Opelka, founder and chair of the PACES Center and a founding member of the Health Care Payment Learning and Action Network and the Surgical Quality Alliance, also cautioned against placing too much faith in the managed care side of the value equation. “Value will not be defined well by a payer, whose only interest is retaining their clients and their margin,” he said. “It will not be defined by surgeons either; we are too close to the applied medical science and too far removed from determining the patient goals of care and if those goals were attained.”
So, where will workable definitions of value come from? “The value expression for specialty care will [be driven by] the specialists defining the limits of what their expertise can do,” he said. “That includes the primary care physician who agrees that the care would be of value to their patient, and from the patient who says if I had to do it all over again, I would,” he said. “That’s value— not some payer-defined standards.”
David Bronstein is a freelance medical writer based in New Jersey.
Disclosures: Dr. Harrill is a co-founder of BridgepointMD. Dr. Opelka is a consultant for the American College of Surgeons, KPMG/State of Colorado, and Third Horizons Strategies. He is the founder and principal of Episodes of Care Solutions, LLC.