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    The fight against paint-by-number medicine

    Many doctors tell a similar story. A patient is responding well to a particular drug or treatment, and it’s inexpensive. Then the payer stops coverage for it, forcing the doctor to try new options, which don’t work as well. 

    The patient becomes stressed as one payer-approved drug after another doesn’t work, and costs rise as doctor and emergency department visits increase. Maybe it ends with the patient in the hospital. The patient isn’t as healthy, the doctor has invested more time and effort, and the payer’s costs are higher than if they had kept paying for the original treatment. 

    The patient, the doctor, and the payer all lose. Yet doctors say this scenario is not uncommon.

    “I understand why payers are doing what they are doing, but I had a diabetic that had her insulin switched four or five times in six years,” says Richard Bryce, DO, a primary care physician in Detroit. “It’s probably cheaper, but it’s not making her life any easier and certainly not making her healthier.”

    Similarly, Peter Bidey, DO, a primary care physician in Philadelphia, had a patient in need of a urological procedure because of a recurring infection. The patient kept getting discharged from the hospital, because the payer wanted the procedure done on an outpatient basis, but this led to four more trips to the hospital and three admissions before it was finally approved.

    “It’s very hard on the patient and such a horrible experience,” says Bidey. “Why don’t they just do the procedure?”

    With value-based contracts becoming more common, some doctors worry that situations like these will create one-size-fits-all medicine, where individual patients and  treatments customized for their particular needs are shoved aside in favor of data-driven treatment plans. But there are steps doctors can take to make sure their voice is heard and that patient care doesn’t become generic.


    Physician concerns about value-based care

    Value-based care focuses on paying doctors for outcomes rather than volume. Doctors are paid more when patients get healthier, as measured, for example, through data such as A1C levels for diabetic patients. But Bryce and other physicians worry that the data-driven approach can be taken too far.

    “The idea of value-based care is great,” he says. “At the same time, it’s important to understand every patient we have is different. Understanding how we are doing and reimbursing us on that is not all bad, but you can’t do it all that way. Just because someone’s A1C levels aren’t dropping doesn’t mean I’m not doing everything I can.”

    Bidey’s concern is that the more data-driven care becomes, the more it will influence what a physician is willing to try. If coverage for a test has been regularly denied in the past, he worries doctors may stop ordering it, even when they believe it is justified. And for requests that are inconsistently approved, it could mean a futile 45 minutes on the phone trying to get a prior authorization when the doctor could be seeing more patients.

    With physicians assuming some financial risk in value-based contracts—if the outcomes aren’t positive, doctors either receive reduced pay or no pay—they should determine how that money is spent, as long as they are following best practices and evidence-based medicine, says Pamela Ballou-Nelson, RN, Ph.D., principal consultant with the Medical Group Management Association. This should include not being limited by prior authorizations, and freedom to consider individual patient needs. 

    Nelson says that value-based care, if implemented properly, should put doctors in a better position to care for patients. But it will require payers to change their thinking and not require doctors to get approval for treatment they deem necessary.

    “If we move into a value-based world, payers have to let go of some of these silly protocols,” she says. “It should free up physicians to be decision-makers again on what the best course of care is.” 

    Next: How payers decide what to approve

    Todd Shryock
    Todd Shryock, contributing author

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      I believe that the physician community has abdicated its true role in patient care.. What other profession that is responsible for an outcome would acquiesce their professional judgement to an entity that has no regard for what that outcome is. Imagine a bridge engineer that is told by the payer of the bridge to change his specifications because he does not want to pay for what the engineer considers essential for the safety of the project. Just as a commuter assumes that a bridge has been built to established safety standards, our patients also assume that we as physicians are in agreement with the care we are recommending. The fact that an insurance company or government entity does not want to pay for it should have nothing to do with our professional recommendation. Until we accept and act as the true advocate for patient care we have taken on oath to protect we will relegated to the role of scapegoat and enabler of the healthcare crises rather than its cure. Our calling is too important. There is no excuse for not doing the right thing.

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